University of Ghana http://ugspace.ug.edu.gh SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA CONTINUING FORMAL EDUCATION FOR NURSES: EXPLORING THE EXPERIENCES OF NON - PROFESSIONAL NURSES IN THE GREATER ACCRA REGION BY EDITH BIAMAH AGYEPONG (10195151) THISTHESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN NURSING JULY, 2017 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses DECLARATION This is to certify that this thesis is the result of research undertaken by Edith Biamah Agyepong towards the Award of Master of Philosophy Degree in Nursing at the School of Nursing and Midwifery, University of Ghana. ……………………………………….. ………………………… EDITH BIAMAH AGYEPONG DATE (STUDENT) ............................................................. ................................... DR. ADELAIDE MARIA ANSAH OFEI DATE (SUPERVISOR) ................................................................. ................................... MRS. ADZO ATSWEI KWASHIE DATE (SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses ABSTRACT Continuing formal education is essential to the growth of the nursing profession due to the dynamic environment of the health industry. Nurses after their initial training received at school, have the opportunity to engage in continuing formal education. The study sought to have an in - depth exploration of the perceptions, motivators, barriers and measures to enhance the continuing formal education of non - professional nurses. The qualitative descriptive design was employed and the purposive sampling technique used to recruit twenty - three non - professional nurses from Pantang Hospital in the Greater Accra Region. The thematic content analysis was used in analysing the data. Four main themes that guided the study were the perception of continuing formal education, motivation for continuing formal education, barriers to continuing formal education and measures to enhance continuing formal education. The findings of the study showed that non - professional nurses have a positive perception about continuing formal education. Motivating factors that encouraged non - professional nurses’ return to school include self - determination and age, low academic qualification and practising outside one’s job description. Barriers to continuing formal education originated from the personal situation of non - professional nurses, educational institutions, the non - professional nurse’s disposition towards school as well as employers and management of healthcare facilities within which non - professional nurses work. The measures to enhance continuing formal education of non - professional nurses include clear educational policies on education and the development of educational programmes to meet the needs of non - professional nurses. The study recommended that continuing formal education should be considered as a collective responsibility of all stakeholders responsible for the continuing formal education of non - professional nurses. Appropriate measures are therefore required by stakeholders to promote the continuing formal education of non -professional nurses. ii University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses DEDICATION I dedicate this work to Mr Enoch Danso Okyere, Akua Amponsah Okyere, and my entire extended family. iii University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses ACKNOWLEDGEMENT I am deeply grateful to my supervisors Dr Adelaide Maria Ansah Ofei and Mrs Adzo Atswei Kwashie for their unflinching intellectual support and guidance. They consistently challenged me to do my best in writing this thesis. I owe a special gratitude to my husband Mr Enoch Danso Okyere whose love inspired me to complete this study. Finally, I wish to acknowledge all lecturers of School of Nursing and Midwifery, University of Ghana, Legon for their mentorship and coaching during my studies which have resulted in the successful completion of this thesis. iv University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses TABLE OF CONTENTS CONTENT PAGE DECLARATION ........................................................................................................................ i ABSTRACT ............................................................................................................................... ii DEDICATION ..........................................................................................................................iii ACKNOWLEDGEMENT ........................................................................................................ iv TABLE OF CONTENTS ........................................................................................................... v LIST OF FIGURES .................................................................................................................. ix LIST OF ABBREVIATIONS .................................................................................................... x CHAPTER ONE ........................................................................................................................ 1 INTRODUCTION ..................................................................................................................... 1 1.0 Background to the Study .................................................................................................. 1 1.1 History of Nursing Education in Ghana........................................................................... 6 1.2 Statement of the Problem ................................................................................................. 8 1.3 Purpose of the Study ........................................................................................................ 9 1.4 Significance of the Study ................................................................................................. 9 1.5 Objectives of the Study .................................................................................................. 10 1.6 Research Questions ........................................................................................................ 10 1.7 Operational Definition of Terms ........................................................................................ 11 1.8 Summary ............................................................................................................................ 11 CHAPTER TWO ..................................................................................................................... 13 LITERATURE REVIEW ........................................................................................................ 13 2.0 Introduction .................................................................................................................... 13 2.1 Conceptual Framework .................................................................................................. 13 2.2 Perceptions of Nurses on Continuing Formal Education ............................................... 17 2.3 Motivation for Continuing Formal Education ................................................................ 21 2.4 Barriers to Continuing Formal Education ...................................................................... 27 2.5 Measures to Enhance Continuing Formal Education of Nurses .................................... 34 2.6 Summary of Literature Review ...................................................................................... 41 CHAPTER THREE ................................................................................................................. 44 METHODOLOGY .................................................................................................................. 44 3.0 Introduction .................................................................................................................... 44 3.1 Research Design ............................................................................................................. 44 v University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 3.2 Research Setting ............................................................................................................. 45 3.3 Target Population ........................................................................................................... 46 3.3.1Inclusion Criteria ...................................................................................................... 47 3.3.2 Exclusion Criteria .................................................................................................... 47 3.4 Sample size and Sampling Technique ............................................................................ 47 3.5 Research Tool ................................................................................................................. 48 3.6 Data Collection ............................................................................................................... 49 3.7 Data Analysis ................................................................................................................. 50 3.8 Data Management .......................................................................................................... 52 3.9 Rigour of the Research ................................................................................................... 52 3.10 Ethical Consideration ................................................................................................... 55 CHAPTER FOUR .................................................................................................................... 57 FINDINGS OF THE STUDY .................................................................................................. 57 4.0 Introduction .................................................................................................................... 57 4.1 Demographic Characteristics of Participants ................................................................. 58 4.2 Perception of Non - Professional Nurses on Continuing Formal Education.................. 58 4.2.1 Acquisition of additional knowledge and upgrading ............................................... 60 4.2.2 Improvement in Care Delivery ................................................................................ 62 4.2.3 Exposure to current trends in the nursing profession .............................................. 63 4.2.4 Raised Economic Standard ...................................................................................... 64 4.3 Motivational Factors for Pursuing Continuing Formal Education ................................. 65 4.3.1 Self - determination ................................................................................................. 66 4.3.2 Low Academic Qualification ................................................................................... 67 4.3.3 Progression in Life................................................................................................... 68 4.3.4 Employers’ recognition for higher academic qualification than experience ........... 69 4.3.5 Lack of professional competencies .......................................................................... 70 4.3.6 Ambition and Drive for Better Career Options ....................................................... 70 4.3.7 Practicing outside one’s Job Description ................................................................. 72 4.3.8 Lack of Respect ....................................................................................................... 73 4.3.9 Influence of Mentors and Role Models ................................................................... 74 4.4 Barriers to Continuing Formal education ....................................................................... 75 4.4 .1 Situational Barriers ................................................................................................. 77 4.4.2 Institutional Barriers ................................................................................................ 78 vi University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.4.3 Dispositional barriers ............................................................................................... 82 4.4.4 Barriers from Employer ........................................................................................... 83 4.4.5 Challenges arising from Management of Health Care Facilities ............................. 85 4.5 Measures to Enhance Continuing Formal Education of Non - professional nurses ..... 87 4.5.1 Clear and Effective Governmental Policies on Education ...................................... 87 4.5.2 Programmes Designed to Meet the Needs of Non - professional nurses ............... 90 4.5.3 Collaboration between Educational Institutions and Health Care Organisations on Educational Opportunities and Programmes .................................................................... 91 4.5.4 Establishment of Mentorship Programmes.............................................................. 93 4.5.5 Organisational Support for Continuing Formal Education...................................... 94 4.6 Summary of Findings ..................................................................................................... 95 CHAPTER FIVE ..................................................................................................................... 97 DISCUSSION OF FINDINGS ................................................................................................ 97 5.0 Introduction .................................................................................................................... 97 5.1 Perception of Continuing Formal Education .................................................................. 98 5.2 Motivation for Pursuing Continuing Formal Education .............................................. 104 5.3 Barriers to Continuing Formal Education .................................................................... 111 5.4 Measures to Enhance Continuing Formal Education ................................................... 120 5.5 Summary of Discussion ............................................................................................... 125 CHAPTER SIX ...................................................................................................................... 128 SUMMARY, CONCLUSION AND RECOMMENDATION .............................................. 128 6.0 Introduction .................................................................................................................. 128 6.1 Summary of the Study .................................................................................................. 128 6.2 Implications of the Research ........................................................................................ 132 6.2.1 Implication for Nursing Practice ........................................................................... 132 6.2.2 Implication for Nursing Education ........................................................................ 133 6.2.3 Implication for Nursing Research .......................................................................... 133 6.3 Insight Gained From the Study .................................................................................... 134 6.4 Limitations of the Study ............................................................................................... 135 6.5 Conclusions of the Study.............................................................................................. 136 6.6 Recommendations of the Study ................................................................................... 137 REFERENCES ...................................................................................................................... 139 Appendix A - Interview Guide ........................................................................................... 145 Appendix B - Individual Consent Form ........................................................................... 148 vii University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Appendix C - General Profile of Participants .................................................................... 152 Appendix D - Summary of Themes ................................................................................... 153 Appendix E - Ethical Approval Letter ............................................................................... 154 Appendix F - Introductory Letter ....................................................................................... 155 viii University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses LIST OF FIGURES Figure 1: Chain of Response Model. ....................................................................................... 14 ix University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses LIST OF ABBREVIATIONS AACN: American Association of Colleges of Nursing ANA: American Nurses Association BSN: Bachelor of Science in Nursing CHPS: Community - based Health Planning Services ENs: Enrolled Nurses GRNMA: Ghana Registered Nurses and Midwives Association IOM: Institute of Medicine QRNs: Qualified Registered Nurses SRNs: State Registered Nurses WASSCE: West African Senior School Certificate Examination x University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses CHAPTER ONE INTRODUCTION 1.0 Background to the Study Education offers important benefits to individuals and their families and plays a critical role in a nation’s economic growth and development. It clearly constitutes public good, serves broad social purposes and goes beyond individual or economic development benefits. Other potential benefits of education include the improvement of social justice through fair access: the pursuit of knowledge for more than commercial ends: the spread of a broad range of skills and capabilities across an entire population and the education of a democratically informed and critical citizenry (Singh, 2001; World Bank/UNESCO, 2000; World Bank, 2005). Health workers particularly nurses also need education because they work in a special field and require knowledge to excel in their career. According to Berings (2006), education is increasingly necessary for nurses to keep abreast with rapid changes in patient care due to advancement in knowledge and technology. Levett- Jones (2005) also emphasised that quality indicators such as nosocomial infections, patient falls, medication errors and pressure sores are distinctly reduced by two vital factors that are, on - going education and an adequate number of skilled personnel. In nursing, nurses have the opportunity to engage in two types of education. These are in - service training and continuing formal education. In - service training may be in the form of continuing professional development, workshops, and seminars. According to the American Nurses Association & National Nursing Staff Development Organisation (2010), in - service training may be defined as a “systematic professional learning experiences designed to augment the knowledge, skills, and attributes of nurses and therefore enrich the nurses’ contribution to quality health care and their pursuit of professional career goals”. Continuing 1 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses formal education, on the other hand, is defined as a form of education which leads to registration of additional qualifications (Searle, Human& Mogotlane, 2009) as cited by (Richards & Potgieter, 2010). Currently, in the developed world, countries such as Australia has made continuing professional development mandatory for nurses, where nurses would have to participate in these programmes periodically to acquire credit hours for renewal of their professional license (Ross, Barr & Stevens, 2013). In contrast, continuing formal education requires that the registered nurse is given the opportunity to pursue post - basic and post - graduate programmes which lead to the attainment of advanced certificates such as diploma, bachelors, masters and doctoral degrees. The two types of education available to nurses may serve the same purpose which is to enhance nurses’ knowledge, attitude, and build on their professional competencies to improve patient care, but the Institute of Medicine’s report on the future of nursing emphasises that, if nurses are to be as effective as possible in providing higher quality and family centered care, they need to be better prepared as healthcare is increasingly becoming more complex and moving into the community. The report conceded that more nurses with advanced degrees are needed to provide primary care and teach the next generations. The report concluded that continuing formal education will assist nurses retain clinical skills and also develop leadership capabilities (Institute of Medicine, 2010). In order to achieve this target, the Institute of Medicine’s report proposed that nursing as a profession strives for a workforce comprising of 80 percent degree prepared registered nurses by the year 2020 and that nurses should engage in lifelong learning (Institute of Medicine, 2011). In spite of the benefits of continuing formal education for nurses, only 50 percent of the current registered nurse's workforce is prepared with a Bachelor of Science in nursing or graduate degree (American Association of Colleges of Nursing [AACN], 2010). In Africa, the 2 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses phenomenon of a low number of nurses with higher education also exists. Fentahun and Molla (2012) found that in Jimma Township, Southwest Ethiopia, only 70(25%) of health care professionals participated in continuing formal education and that, as working experience increased, participation in continuing formal education did not steadily increase. The authors concluded that participation of health care professionals in continuing formal education was low. Similarly, in Uganda, Muliira, Etyang, Muliira and Kizza (2012) carried out a research to measure the orientation of 200 nurses at the Uganda’s national hospital towards lifelong learning. The authors concluded that nurses’ orientation towards lifelong learning remains low, and this has implications for successful implementation of continuing education programmes for nurses. The situation of a low number of nurses in continuing formal education also persists in Ghana. Notwithstanding, the fact that quite a number of nurses have received training from the university or nurses’ training colleges, there are, however, non - professional nurses who pursue a two - year basic training in nursing to assist the professional nurse in the performance of their duties. There are two groups of non - professional nurses in Ghana: (1) Nurse assistant preventive also known as community health nurses who are trained for preventive health services and work within the communities and villages, to assist the public health nurse in using human and material resources in the community to promote and maintain health, prevent and control communicable diseases as well as aid in rehabilitation. (2) Nurse assistant clinical also called enrolled nurses work in either the community or hospital to assist the professional nurse in performing her duties such as undertaking simple procedures like making beds, feeding and cleaning patients etc. According to (Böhmig, 2010), the training of non - professional nurses has been in existence since the inception of nursing education in Ghana in 1945. Nurse assistants who were recruited were given apprenticeship training in basic hygiene, physiology; 3 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses medical and surgical nursing on the wards, but through educational reforms, nursing training in Ghana has now achieved a tertiary education status. In the 21st century, it is the aspiration of every nurse to become a professional, but unfortunately, some find themselves in the non - professional group of nurses. This category of nurses after completion of their basic training in nursing are posted to various health facilities in the country to work, especially in rural areas. After working for three to five years, these non - professional nurses realise their situation is not good enough because they are at the lowest level of the nursing profession and are also deficient in knowledge and skills. What worsens their plight is that there is no career mobility and educational advancement for them. As young as the majority of these nurses are, the farthest designation the non - professional nurse can attain is either a superintendent enrolled nurse or a superintendent community health nurse. As a result, non - professional nurses feel they should be given the chance to continue their education in a formal way as their professional counterparts who can progress both academically and professionally in the nursing profession. One may argue that, in - service training in the form of conferences, seminars and workshops are organised for these non - professionals in the form of continuous professional development by their prospective professional associations and to a lesser extent by universities, nursing colleges and other institutions (Badu-Nyarko, 2015), but nurse assistants need continuing formal education to help them advance in knowledge. Aiga and Kuroiwa (2006) maintained that health workers are the most important assets of any healthcare system thus the need for them to learn and apply new skills and knowledge. The authors further conceded that without such learning opportunities, nurses would be dissatisfied professionally, have a decrease in their skills and knowledge base and a reduced interest in their work. 4 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses From the foregoing argument, continuing formal education is equally important for non - professional nurses as their professional counterparts who are privileged to advance both professionally and academically. However, little is known about non - professional nurses and continuing formal education in Ghana. This study is undertaken to address this gap. The study intends to find out the experiences of non - professional nurses with continuing formal education. The study will delve into the perception of non - professional nurses on continuing formal education which is likely to be influenced by their experiences with continuing formal education, their motivational factors for continuing formal education, the barriers non – professional nurses encounter in their attempt to pursue further studies and measures that can be put in place to enhance their continuing formal education. An insight into the perceptions, motivators and barriers encountered by non - professional nurses will assist in the development of educational and training programmes that meet the professional needs of these nurses. The study was guided by the Cross Chain of Response Model (Cross, 1981) developed by Kathryn Patricia Cross which seeks to explain an adult’s decision to either participate in an educational programme or not. The model is a cycle and comprises seven steps which all have their impact on the decision an individual has to make whether or not to participate in an adult education programme. The Cross Chain of Response Model (Cross, 1981) focuses on the adult’s self-perceptions regarding education, his attitude towards education, the value he places on education, his expectations from engaging in an educational programme, the influence an adult’s life transitions have on his decision to engage in an educational programme and how the information he receives regarding and educational programme influences his decision to partake in an adult education. Cross’ model also examines how the barriers and opportunities associated with engaging in an educational programme affects the adults decision to either not to return to school or not. 5 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 1.1 History of Nursing Education in Ghana Nursing education in Ghana has undergone tremendous changes. Nursing in Ghana started as a hospital - based activity in the 20th century where male ward assistants or orderlies were trained to assist the British sisters on the ward. The ward assistants received on - the - Job training in human anatomy and physiology, hygiene, medical and surgical nursing and first aid. This training was considered to be of a low standard because the ward assistants carried out basic activities in nursing. In the mid 1940’s, the director of medical services, Dr Balfour Kirk, saw the need for an accelerated programme to train nurses to acquire an advanced education in nursing comparable with how the British trained their nurses. This led to the formal training of nurses in Ghana. Nurses who graduated from this training were called State Registered Nurses (SRNs). The aim of their training was to equip them with knowledge and skills which will enable them serve as supervisors and administrators who would replace the British nurses in the hospitals when they leave the country (Addae1996:169: as cited in Bohimg, 2010). The main duties of the SRNs were to give care to the sick and carry out procedures such as giving treatment to the sick as well as diagnosing surgical, medical and pediatric patients. The number of (SRNs) remained low as a result of low salary, strict discipline and rigid working times. The decrease in the number of (SRNs) required that more nurses are trained to support the nursing work. This brought about the training of Qualified Registered Nurses (QRNs) in 1946 who were middle school leavers and were given apprenticeship training by the SRN’s in less detailed sciences. The QRN’s mainly worked at the health posts (Otoo 1968:86 as cited in Bohmig 2010). In 1957, when Ghana attained independence, the first government at the time realized the need to train more nurses who would work in the hospitals and in specialized areas such as public health nursing so that nursing services could be sought after in the entire country. Nurses were then trained in public health nursing. Their training centered helping the nurses to acquire 6 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses knowledge about the various disease conditions and how the physical, biological and social environment impacts on a disease condition. (Akiwumi 1995:26 as cited by Bohmig, 2010). The public health nurses were also to focus on strengthening the preventive aspect of disease conditions so as to avoid overloading of the hospitals. The extensive nature of the work of the public health nurses brought about the training of community health nurses in 1960, who were to assist the public health nurses in carrying out their duties. These community health nurses were females with middle school certificate who received two years training in community health nursing and worked in the urban and remote areas to assist the public health nurse. In 1968, the training of QRNs was terminated and this resulted in shortage of nurses and an increased workload, as a result auxiliary nurses were needed to support the State Registered Nurses and this led to the recruitment of Enrolled Nurses (ENs). Their training was shorter and less detailed. Enrolled Nurses were to meet the needs on the wards until sufficient trained nurses were available; each hospital could train them according to their needs. The enrolled nurses were from villages and poorer families with lower academic qualifications. In the mid- 1980s, the training of enrolled nurses was also stopped. Both QRN’s and EN’s were offered the possibility to upgrade their knowledge by furthering their education to become professional nurses, but only a few of them continued their education. Majority of these auxiliary nurses did not return to school because they were satisfied with their work whereas others were also less motivated to return to school books. According to Akiwumi (1995) as cited in Bohmig (2010) by the year 1980, the number of enrolled nurses exceeded the number of State Registered Nurses (SRN) in the country. The enrolled nurses worked under the supervision of the State Registered Nurses. Although nursing education in Ghana started with the training of auxiliary nurses, the country can now boast of universities and nurses training colleges which offers formal education to nurses (Böhmig, 2010). 7 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Although the training of community health nurses has been in existence since the 1960’s, anecdotal evidence suggest that the training of new cadre of auxiliary nurses in Ghana begun in the year 2008. These auxiliary nurses are called enrolled nurses (Health Assistant Clinical). The aim of their training was to equip them with basic knowledge in nursing to assist professional nurses carry out their duties in all hospitals and health post throughout the country as due to shortage of nurses. The training of these auxiliary nurses was to be in existence for a while as their appointments will be terminated in later years when there are adequately trained professional nurses to take up the nursing work but as a result of political gimmick in the country (Quaicoe-Duhol, 2014), the training of these non - professional nurses has been in existence to date with only one academic progression opportunity available to them, which is to be trained as midwives to acquire a basic qualification of a certificate in midwifery after working for a period of three to five years within the Ghana Health service. 1.2 Statement of the Problem Nurses are being confronted daily with knowledgeable clients who are insisting on quality health services, demanding accountability and competence from all clinicians, thus the nursing profession is no longer satisfied with mediocrity. This is an indication that the nursing profession values higher education as a means to build competencies at all levels. Research has shown that healthcare facilities with a greater number of nurses who have undergone continuing formal education records low numbers of congestive heart failure mortality, decubitus ulcers, postoperative deep vein thrombosis and clients also have a shorter stay in such facilities (Blegen, Goode, Park, Vaughn &Spetz,2013). This emphasises the fact that participation in continuing formal education is essential to non - professional nurses who find themselves at the basic level of the nursing profession but have huge potential for development. Educational opportunities exist for all nurses in Ghana to advance in knowledge, but it is challenging for non - professional nurses to return to school. The majority of these nurse 8 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses assistants enter the profession at a young age of about eighteen (18) years. Once these nurses begin working and receive regular income, the next thing to do is marry and have children. Juggling family responsibilities, child care and work become so demanding that they find it difficult to further their education. Studies have been conducted on continuing formal education and its importance for professional nurses in Ghana (Aiga & Kuroiwa, 2006; Bell, Rominski, Bam, Donkor, & Lori, 2013), but there is paucity of literature on whether the non - professional nurse will return to school or not. Non - professional nurses’ perception about continuing formal education, what factors motivate them to pursue further studies, the challenges they encounter in their pursuit of continuing formal education and measures to solve these challenges have rarely been a topic for research. Is it because these non - professional nurses are content with their level of education or they wish to further their education as their professional colleagues? Do non - professional nurses regard their level of education as a threat to themselves in terms of being able to aspire to greater career opportunities in the nursing profession? This study intends to address this gap. 1.3 Purpose of the Study The purpose of the study was to explore the experiences of non - professional nurses with continuing formal education. 1.4 Significance of the Study The findings of the study will provide insights into the perceptions (experiences), motivators and barriers regarding continuing formal education of non - professional nurses and the support structures that can be put in place to overcome the identified barriers to continuing formal education. 9 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses The study is also essential as it will contribute to the restructuring of the nursing profession to improve health care delivery. The findings of the study will add to existing knowledge on nursing educational mobility as well as echoing the need for a revision of nursing education for non - professional nurses in Ghana. Finally, the results of the study will also generate interest in further research on the importance of education for non - professional nurses. 1.5 Objectives of the Study 1. Explore the experiences (perception) of non - professional nurses on continuing formal education. 2. Evaluate the factors that motivate non - professional nurses to engage in continuing formal education. 3. Examine the barriers to continuing formal education encountered by non - professional nurses. 4. Identify measures that would promote continuing formal education of non -professional nurses. 1.6 Research Questions The following research questions were designed to guide the researcher in the study: 1. How do non - professional nurses perceive continuing formal education? 2. What factors motivate non - professional nurses to pursue continuing formal education? 3. What barriers do non - professional nurses encounter in their desire to continue their education? 4. What measures can be put in place to promote the continuing formal education of non - professional nurses? 10 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 1.7 Operational Definition of Terms Continuing Formal Education: Structured learning designed for non - professional nurses with basic qualification to engage in formal classroom learning for at least a year with an aim of acquiring a higher certificate in their field of study. Non - professional Nurse: A male or female nurse assistant clinical (enrolled nurse) or nurse assistant preventive (community health nurse) who has completed a two - year certificate programme in nursing. Experience: The lived stories of non - professional nurses regarding continuing formal education which is likely to influence their perception towards continuing formal education. Perception: The way a non - professional nurse thinks or understands continuing formal education. Motivators: Factors influencing non - professional nurses to engage in continuing formal education. Barriers: Factors that make it difficult for non - professional nurses to engage in continuing formal education. Measures: Solutions that can be put in place to promote the continuing formal education of non - professional nurses. 1.8 Summary This chapter focused on the importance of continuing formal education to the non - professional nurse who may either be a community health nurse or an enrolled nurse and had received a two - year basic training in the nursing profession to assist the professional nurse in the performance of her duties. In spite of the fact that non - professional nurses are given in - service training in the form of workshops, seminars and conferences to augment their work professionally, there 11 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses is the need for these nursing assistants need to engage in continuing formal education to assist them render quality services to their clients. Thus the study seeked to find out non - professional nurses’ experiences with continuing formal education, by concentrating on their perceptions regarding continuing formal education, what factors will motivate them to partake in continuing formal education, the barriers they encounter and measures that can enhance their further engagement in an educational programme. The study was guided by the Cross Chain of Response Model (Cross, 1981) which explains an adults decision to either participate in an educational programme or not. The research questions guiding the study were developed based on the constructs of the Cross Chain of Response model. 12 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter presents the empirical literature related to the study. The chapter has been organised as follows: conceptual framework guiding the study, the perceptions of nurses on continuing formal education, motivational factors to continuing formal education, barriers to continuing formal education and measures to enhance continuing formal education. 2.1 Conceptual Framework In this study, the researcher examined the problem from the perspective of adult education and to do this, the Cross Chain of Response Model was used (Cross, 1981). This model is an appropriate framework to investigate the perceptions, motivators and barriers non -professional nurses encounter in their quest to continue their education as the model explains why an adult would decide to either participate in an educational programme or not. The Cross Chain of Response Model is a cycle and comprises seven steps which all have their impact on the decision an individual has to make whether or not to participate in an adult education programme. According to Cross (1981) an adult’s perception (A) regarding education influences his or her attitude towards education (B), his or her values of goals and expectations that participation in educational programme will meet goals (C). Cross further adds that the individual’s life transitions (D), information received regarding an educational programme (F), opportunities and barriers to the programme (E) will influence the adult’s decision whether or not to participate (G) in any form of adult education. Each stage in Cross’ model is influenced by the other; the more positive the learner’s experience at each stage, the more likely the learner is to reach the last stage which is the decision to participate in adult education (Cross, 1981). 13 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Source: Cross (1981) Figure 1: Chain of Response Model In explaining the chain of response model, Cross posits that the adult’s self - perception (A) about education will make him or her develop either a positive or negative attitude (B) towards learning. Adults with past negative learning experience have low self - esteem and confidence, enjoy learning less and thus develop a less positive attitude towards learning. These factors of attitude and self - perception interact with the value he or she places on education and what he expects to gain from participating in an educational programme (C) (Cross,1981). Cross maintains that the individual will value adult education if it will meet his or her expectation in life such as having more social contacts and increased income, job success and a better performance within daily activities. These expectations and values are influenced by life transitions (D) undergone by the individual and also interact with the opportunities and barriers to adult education (E). Although there may exist opportunities to education, Cross contends that barriers can hinder an adult’s participation in an educational programme. The barriers to an adult’s engagement in an educational programme are the central concept in the work of Cross and one of her most cited ideas. These barriers are divided into three main 14 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses categories, namely situational barriers, institutional barriers and dispositional barriers. Situational barriers emanate from the personal situation of an adult at a given moment which deters his or her decision to engage in an educational programme. Examples of situational barriers include lack of transport possibilities to reach the educational institutions, lack of time to follow an educational programme due to job and family responsibilities and lack of money to finance the educational programme. Institutional barriers arise when educational institutions establish rules and practices which sometimes discourage majority of adults from participating in an educational programme. Entrance requirements, inconvenient class schedules, and a lack of study device among others are examples of institutional barriers. Dispositional barriers are linked to the adult’s self - esteem, perceptions, feelings and attitude towards education that undermine his confidence to enroll in an educational programme. Examples of dispositional barriers include feeling frustrated after an unsuccessful educational career, being disgusted by classrooms and teachers, feeling too old and lack of preparedness towards learning. The kind of information the adult receives regarding the existing educational opportunities and barriers to an educational programme can also affect the decision - making process of an adult whether or not to participate in an educational programme. The last step in Cross model looks at how the adult after going through the first six steps in the cycle makes the decision to either participate in an educational programme or not. According to Cross (1981) after a successful enrollment in a programme of study, the cycle starts all over again. A fail within the cycle leads to a dropout and a successful passing through the cycle results in persistence. Burton, Lloyd and Griffiths (2011) contend that the barriers identified in Cross’ model do not disappear even after the individual has made the decision to participate in an educational programme. These barriers may persist and mount a higher or a lower pressure on the adult throughout the period he or she is engaged in a programme of study. 15 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Several researchers in various disciplines of study have used Cross model to find out the adult learners’ perceptions, motivations and barriers to education. An example is Gorczyca (2013) who conducted a qualitative study to examine the attitudes, perceptions, motivators and barriers to continuing formal education among registered nurses working in a large urban hospital who have never enrolled in graduate education. Her study revealed that nurses did not have a positive perception about returning for graduate studies. The reasons given for not enrolling in graduate programmes included alternative educational opportunities, non - availability of graduate careers, theory practice gap, inability to weigh the value of graduate education and misconceptions of graduate level roles. Factors that motivated registered nurses to pursue continuing formal education included having a professional goal, being personally and professionally challenged and having a role model in the form of peer support and mentorship. The situational barriers to continuing formal education which prevented nurses from pursuing further studies included family commitments; age, financial impact and work - life balance. Institutional barriers included the rigidity of the application processes involved in the enrollment of a programme. The main dispositional barrier was a lack of energy to return to school. These findings are congruent to the Cross Chain of Response Model. Burton, Lloyd and Griffiths (2011) also used Cross chain of response model to investigate whether the traditional barriers to learning still existed for mature adult learners who were pursuing higher education. The study participants were eighty - four students who were above twenty-one years and had already enrolled in programmes such as health, social and childcare in a further education college in South Wales. The main motivating factor identified for pursuing the educational programme was to obtain qualifications to enhance their employment prospects. The findings also revealed that Cross’ three types of barriers did not hinder students’ participation in continuing formal education as a result of the initial contacts the school made 16 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses with potential students in the early processes of enrolling in the programmes of study, and this appeared to alleviate the fear students had in returning to school. In addition, the school had instituted support systems to help students from the start to the end of the programme which helped students to persist in the programme until completion. Although the Chain of Response Model explains the complex interaction between an individual and his or her environment, it focuses mainly on the decision the individual has to make single handily either to participate in an educational programme or not. This approach of presenting processes gives the impression of a unilateral responsibility of the individual towards pursuing adult education but implementation of good institutional support from educational institutions as well as the regulating governments could also facilitate the adult’s participation in an educational programme. Blythman and Orr (2002) maintain that once the learner has made the bold decision to participate in further education, educational institutions should fashion out strategies to enable all students to study successfully. Though the Cross’ Chain of Response Model looks at the interplay of seven factors which influence the individual’s decision to either participate in an adult education programme or not. This study will focus on how non - professional nurses’ perception, values of goals and expectations that participation in education will meet goals (motivating factors) and barriers to participating in an educational programme influence the non - professional nurses’ decision either to participate in continuing formal education or not. 2.2 Perceptions of Nurses on Continuing Formal Education Perception is the process by which organisms interpret and organise sensation to produce a meaningful experience of the world. An individual’s perception about education influences his or her decision whether or not to engage in continuing formal education (Cross, 1981). 17 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses In a qualitative exploratory study conducted by Osterman, Asselin, and Cullen (2009) to examine the perceptions of registered nurses who had pursued degree in nursing and the impact of the degree on their practice; eleven (11) registered nurses who were all women with their ages ranging from 40 to 50 years were purposively sampled to participate in the study. These nurses had worked in an acute care hospital between 14 and 34 years and most of the participants had their basic education as an associate degree in nursing. The findings of the study revealed that nurses perceived continuing formal education as expanding their knowledge of the nursing profession as well as enhancing their personal satisfaction. These findings are confirmed by Sarver, Cichra and Kline (2015) in their study to elicit nurses’ perception about continuing formal education. The authors found that nurses’ perceived engaging in continuing formal education as a means of increasing their opportunities to get jobs, expand their knowledge and gain personal satisfaction. Furthermore, nurses perceive engagement in continuing formal education as a means of enhancing their professional skills and competencies. Ni et al. (2014) performed a cross - sectional survey of 2727 hospital - employed Chinese nurses working in ten general hospitals from September to October 2010. Their study which aimed at exploring Chinese nurses’ attitudes and perceptions on continuing formal education, as well as motivational and preventive factors to continuing formal education found that more than 92.8% of the nurses perceived continuing formal education as necessary and important. The study concluded that Chinese nurses attach importance to continuing formal education because it has the potential of enhancing their professional competencies. Further studies confirmed how nurses perceived continuing formal education as valuable and greatly important to their profession (Baxter et al., 2013; Govranos & Newton, 2014; Nsemo, John, Etifit, Mgbekem, & Oyira, 2013). Richards and Potgieter (2010) also maintained that nurses perceived continuing formal education as 18 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses beneficial to their personal, professional growth, and also brings about improvement in the quality of care delivered to patients. Nurses hold the perception that by engaging in continuing formal education; their care giving skills would improved. Lerner, Resnick, Galik and Russ (2010) in their single group pretest and posttest study to find out if nurse assistants in Maryland, Pennsylvania and Delaware required additional education to supplement their basic training, confirmed that nursing assistants who enrolled in the advanced training programme showed an interest in acquiring additional education as they believed participating in it will enhance their care giving skills, increase their job satisfaction and also lead to an improvement in the quality of nursing care. Nsemo, John, Etifit, Mgbekem and Oyira (2013) also opined that nurses are of the mindset that by engaging in continuing formal education, they would be able to build on their professional competencies so as to meet the needs of their patients. In addition, nurses perceive furthering their education as a means to progressing on the pathway of the nursing profession. Perfetto (2015) in his meta - synthesis of qualitative studies to find out the experiences of nurses returning to school for baccalaureate education, found that majority of nurses perceive advancing their education as a means to fulfilling themselves as nurses, maintaining their professional status as well as refreshing their perspectives about the profession. Some nurses also perceived returning to school as exposing them to the larger world of nursing where they are likely to come across current trends, stay up to date with current happenings and upgrade their knowledge about the profession (Nsemo et al., 2013; Perfetto, 2015). The literature search also points to the fact that nurses perceived engaging in continuing formal education as helping them to retain their jobs. 19 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Pool, Poell and Ten Cate (2013) in their qualitative study involving 22 nurses and 10 managers in three varying age groups who work in various wards in a Dutch University medical centre to determine their perception and barriers to continuing formal education, maintained that nurses perceived continuing formal education as enhancing their social status and self - esteem. Majority of the nurses in their study, wanted to engage in programmes which will lead to enhancement in salary and career advancement. In addition, the literature search revealed that nurses’ attitude about continuing formal education informed their perception of returning to school. Altmann (2012) examined the attitudes of nurses, initially registered with an associate degree or diploma in nursing towards continuing formal education in a survey. Five hundred and thirty five actively licensed registered nurses in the eastern and western United States participated. The findings of the study indicated that the attitude of all nurses towards continuing education require improvement. Nurses who had returned to school had the most positive attitude about continuing formal education, with positive attitude related to personal reasons, social pressure and experience. Maneval and Teeter (2010) confirmed the positive attitude of nurses towards continuing formal education. In their survey to find out the views of associate degree and diploma nursing students on their future educational goals regarding the proposed educational advancement legislation of registered nurses pursuing baccalaureate education 10 years after their initial registration in Pennsylvania. The survey consisted of five items, each addressing specific questions related to students’ self - reporting of educational goals and their opinions related to proposed legislation. The authors used a total of 4,390 students with diploma students being 1,541 and associate degree nurses 2,849. The results of the study indicated that the majority of respondents (86.3 %) planned to pursue the bachelor’s degree in nursing, most (94.8 %) hoped to be enrolled in a BSN programme within four years of graduation. The survey concluded that the vast majority 20 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses of associate degree and diploma nursing students value and hope to pursue higher education in nursing. The abovementioned literature search shows that nurses’ perceive continuing formal education as a means to expanding their knowledge of the nursing profession, enhancing their personal satisfaction, increasing their chances of getting jobs, heightening their professional competencies and acquiring knowledge to improve upon their care delivery skills. 2.3 Motivation for Continuing Formal Education This section of the literature review focuses on factors which motivate nurses to pursue continuing formal education. As regards personal satisfaction, Shahhosseini and Hamzehgardeshi (2015) interviewed 361 nurses’ using the exploratory sequential mixed methods to determine factors which influence nurses to participate in continuing formal education, the authors sustained that irrespective of the fact that continuing formal education was mandatory in some provinces and nurses needed the grades obtained from participating in continuing formal education for promotions and other assessments, nurses were motivated to further their education because they wanted to update their professional knowledge as well as enhance their clinical skills. The nurses in their study opined that by engaging in continuing formal education they stood the chance of learning new skills in addition to their routine practices. Warren and Mills (2009) also indicated that higher professional commitment of nurses served as a source of motivation to pursue additional education. Emphasizing higher professional commitment as a motivator for nurses in pursuing continuing formal education, Richards and Potgieter (2010) in their quantitative descriptive survey to ascertain the perceptions and barriers to continuing formal education used 40 registered nurses 21 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses who held senior level managerial positions in two tertiary hospitals, a primary healthcare facility and a secondary level facility. The authors confirmed that nurses engaged in continuing formal education because they want to acquire more knowledge and skills which they did not obtain from their basic training. Similarly, Ni et al. (2014) also highlighted in their survey that majority of nurses, that is above 60.3% identified five factors that motivated them to participate in continuing formal education. These factors included; to obtain knowledge that would help them achieve their professional status, elevate their level of scholarship, improve their skills in clinical practice, enhance the quality of their understanding of the nursing profession as well as update their knowledge. In addition, nurses are personally motivated to engage in continuing formal education as a result of acquiring additional qualifications to the ones they already had (Ni et al., 2014; Richards & Potgieter, 2010). Furthermore, nurses are motivated to return to school, if they found educational programmes very important to their profession (Brekelmans, Maassen, Poell, Weststrate & Geurdes, 2016). In as much as nurses are motivated to engage in continuing formal education as a result of building on their professional competencies, some nurses opined that building on professional competencies did not only bring about improvement in care delivery but also clients gained satisfaction from the care given when their expectations were met (Richards & Potgieter, 2010). Nurses’ motivation to pursue further studies may result from the incentives provided by organisations within which they work. A cross - sectional survey, using descriptive statistics to evaluate perceived barriers, motivators, and benefits of returning to school for the Bachelor of Science in Nursing (BSN) degree was conducted by (Sarver et al., 2015). The authors carried out the study at a large urban medical facility using the investigator - developed anonymous survey to elicit responses from 332 participants. The findings of the study indicated that flexible 22 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses work hours and tuition reimbursement by organisations were among the factors which motivated nurses to pursue advanced education. Additionally, Warren and Mills (2009) in their descriptive cross - sectional study using 297 actively licensed associate degree or diploma nurses in Maryland, who were below the age of 50 years, works 20 hours or more per week in an acute care hospital and had not pursued a degree in nursing or any higher nursing degree programme at the time of the study found that higher professional commitment and organizational incentives encouraged nurses to return for an additional nursing degree. Several studies also concluded that nurses were motivated to go to school because the hospitals within which they worked were ready to pay a greater percentage of their tuition fees (Nsemo et al., 2013; Perfetto, 2015). Power et al. (2011) sustained that pharmacists were more motivated to pursue continuing formal education when they had confidence in the available programmes, had support from their workplace and the educational programmes were designed to meet their learning needs. Richards and Potgieter (2010) also opined that peer encouragement, assistance from management and the existence of role models in organisations where nurses worked were major motivators which influenced nurses to participate in continuing formal education. In addition, the duration and flexibility of programmes and the support given to students by educational institutions more often compel nurses to return to school (Sarver et al., 2015). Nurses are motivated to pursue continuing formal education due to the availability of new educational programmes which are convenient and easily accessible (Perfetto, 2015). Burton, Lloyd and Griffiths (2011) confirmed that close association of educational institutions with potential students before their enrollment in a programme of study, as well as the support offered to students from the start to the end of their programme encourages students to stay on the programme until completion. Duffy et al. (2014) also emphasised that nurses are likely to 23 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses return to school if they would receive financial support from the educational institutions and the organisations within which they work. Nalle,Wyatt and Myers (2010) maintained that nurses are motivated to participate in continuing formal education when programmes designed by educational institutions meet their needs as learners. In their survey to assess the learning needs of six hundred and seventy - two state registered nurses, their findings revealed that nurses were more interested in leadership and management, evidence based practice and advanced practice programmes. The opportunities associated with continuing formal education also encourages nurses to return to school. According to Warren and Mills (2009) nurses have the belief that a Bachelor of Science in Nursing degree offers greater job and promotional opportunities. Buhr (2010) also undertook a study which sought to determine whether a high probability of being promoted to the next rank was as a result of increasing one’s educational level. Data from the confidential master files from the 2001 Canadian census on individuals were used for the study. The study provided empirical evidence to show that registered nurses with a bachelor’s degree stood a better chance of being promoted to supervisory positions. Samples comprising both males and females indicated that a bachelor of nursing degree yields a 4% probability of being promoted to a supervisory position as compared with other educational credentials. In a similar way, a plethora of studies suggests that continuing formal education offered the nurse opportunities to gain research and critical thinking skills required to assume higher level positions in the domains of administration, education, research, advanced clinical practice and leadership (National League for Nursing 2011; Plunkett, Iwasiw, & Kerr, 2010; Osterman et al., 2009). Witt (2011) posited that participation in continuing formal education grants the nurse the opportunity for career growth, networking and exposure to new opportunities such as 24 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses attending national and international conferences. These conferences provide the platform for poster presentation of best practices and new researches. Studies show that nurses are motivated to engage in continuing formal education as a result of the new insight they got into the profession which greatly influences their practice. The change in one’s personality after school is also a major motivating factor which encourages nurses to go to school. Nurses feel empowered, have increased confidence levels, become assertive and are able to interact and work more effectively with members of the healthcare team. Nurses confirmed how the transformative learning experiences helped them to have professional goals and renew their excitement for learning (Perfetto, 2015; Tame, 2013). A number of nurses are also motivated to participate in continuing formal education by encouragement and support from family and friends. Alamri and Sharts-Hopko (2015) performed an exploratory descriptive study from universities, colleges, and hospitals in the western region of Saudi Arabia with a convenience sample of 158 participants. The study sought to identify motivational factors for returning to school for a Bachelor of Science in nursing degree in Saudi Arabia and the barriers they encounter. The findings from the study revealed that women are significantly more motivated by their families than men to return to school and nurses are personally satisfied to pursue continuing formal education. In addition the study found that, the increasing demand for advanced training of registered nurses in all settings motivated nurses to go back to school. Some nurses were also motivated to further their education as a result of the encouragement they received from friends and colleagues who were returning to school. Their findings also suggested that younger nurses are more motivated to pursue continuing formal education than older nurses. Nurses who have had 7 or more years of working experience were highly motivated to pursue continuing formal education than those with less working experience. 25 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Studies also affirm that nurses are motivated to pursue continuing formal education as a result of the physical nature of their job and their advancing age. Some nurses by re - examining the prospects they stand to gain from the nursing profession, wanted to escape from the seven days a week, twenty - four hours a day and the three hundred and sixty-five days a year nursing work. Nurses are looking for career options where they do not have to work for twelve hours a shift and on holidays (Perfetto, 2015; Richards & Potgieter, 2010) Development of leadership qualities is also a factor which motivates nurses to engage in continuing formal education. According to Richards and Potgieter (2010) nurses engage in continuing formal education because they want to build on their leadership capabilities and also serve as mentors who will guide newly qualified nurses and students who worked under them. The literature further points to the fact that nurses are motivated to return to school, if their previous education and experiences are appreciated by faculty and that, the educational institution is ready to accept them as individuals with distinctive needs and perspectives and are also prepared to assist them to advance in knowledge by giving them basic skills in computing, writing and how to effectively learn so as to cope academically (Perfetto, 2015). Furthermore, some nurses are motivated to return to school because it is a mandatory requirement of their state, while others also feel it is their responsibility to continue their education so as to enhance their personal development in life (Nsemo et al., 2013). Similarly, Pool et al. (2013) found that nurses who participate in continuing formal education have an inward desire to develop academically. The literature search points out that although continuing formal education programmes were challenging for some nurses, dedication and commitment on the part of these nurses motivated them to stay and complete their programmes of study (Perfetto, 2015). Richards and Potgieter (2010) in their study also confirmed that nurses are motivated to return to school if they were assisted in developing career pathways. 26 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses A comprehensive review of the literature suggests that factors that motivate nurses to pursue continuing formal education emanate from the individual’s personal satisfaction, the desire to build on one’s professional competencies, organisational incentives towards continuing formal education, support from educational institutions and the opportunities associated with continuing formal education. 2.4 Barriers to Continuing Formal Education Nurses are motivated to pursue continuing formal education, but there exist barriers which may deter or hinder their decision to return to school. These barriers may be divided into three main categories namely; situational barriers, institutional barriers and dispositional barriers as described by Cross Chain of Response Model (Cross, 1981). Situational barriers emanate from the personal situational of an adult at a given moment. Schweitzer and Krassa (2010) reviewed ten published research studies from 1990 to 2008 on the barriers that deter nurses from engaging in continuing formal education. The sample comprised studies examining reasons for non - participation in continuing formal education among nurses. A descriptive analysis was carried out to compare the research studies’ designs and instrumentation, samples, results and implications. The authors concluded that childcare and home responsibilities, inability to get time off from work and the cost of attending continuing formal education are the most frequent situational deterrents to participation in continuing formal education. Additionally, nurses acknowledged factors like time limitation, work responsibility, fatigue, lack of information about continuing formal education programmes, the cost of courses and the relevance of the educational programmes as preventing them from participating in continuing formal education (Baxter et al., 2013; Nalle et al., 2010; Ni et al., 2014). 27 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Hutchinson, Mitchell and St John (2011) conducted a qualitative study using focus group interviews to ascertain the barriers encountered by Australian enrolled nurses with diploma who had enrolled into the second year of a bachelor of nursing programme and the methods employed by these nurses to adapt to the academic environment. The authors found that nurses who had families and had enrolled in the programme could not go through socialisation processes while in school because they felt engaging in such social activities distracted them from their studies. Similarly, Rouse and Rooda (2010) in their qualitative study using the mixed method approach to find out, why nurses who had enrolled in an accelerated eighteen months Bachelor of Nursing programme instead of the traditional nursing programme failed to complete their programmes of study, opined that the health of a family member or the student herself, having to take up extra jobs in order to care for one’s family, the desire to pursue educational programmes on sandwich basis and dismissal from school are barriers encountered by nurses while in school. Similarly, Ikenwilo and Skåtun (2014) carried out a study on non - training graduate doctors working in the national health service in Scotland to evaluate doctors perceptions of their needs and barriers to continuing formal education. Their study revealed that barriers which prevented doctors from going back to school included lack of funding, long distance to educational centres, lack of clinical cover and lack of time. Duffy et al. (2014) also confirmed that economic issues and difficulties balancing work with one’s personal life prevented nurses from enrolling in continuing formal education programmes as well as completing their programmes of study. Institutional barriers may also deter nurses from furthering their education. These barriers may originate from educational institutions that are charged with the responsibility of providing training for nurses. The high cost of tuition fees by educational institutions prevents nurses from going to school. In a study conducted by Chong, Francis, Cooper and Abdullah (2014) 28 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses to explore current educational practices and future needs among seventy thousand registered nurses working in one hundred and seventy - eight ministries of health hospitals and community clinics in Malaysia, the authors found that nurses did not engage in continuing formal education because the courses were full time and the universities were located in cities. Eventhough some public universities offered online courses for nurses the cost deterred them from pursuing tertiary education. Baxter et al. (2013) confirmed that the time duration involved in completing a programme of study dissuades nurses from participating in continuing formal education. In their study to find out the continuing formal education needs of primary health care nurse practitioners in Ontario, Canada, the authors maintained that the nurses did not participate in continuing formal education programmes due to the fact the programmes of study required longer duration for completion. Another institutional barrier which deters nurses from furthering their education is the few number or unavailability of continuing formal education programmes (Ikenwilo & Skåtun, 2014). Highlighting the fact that, lack of educational programmes deterred nurses from engaging in continuing formal education, Bell et al. (2013) who researched into the challenges confronting nursing education in Ghana sustained that, the number of nurses who qualified to enroll in a continuing education programme far outnumbered the available educational opportunities. Lack of advertisement on educational programmes also hinders nurses’ participation in continuing formal education. Richards and Potgieter (2010) opined that late advertisement of educational programmes and lack of appropriate programmes deterred nurses from continuing their education. Research further shows that, in as much as nurses wanted to engage in continuing formal education, provision of continuing professional development programmes 29 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses such as conferences, in - service training and workshops prevented nurses from pursuing advanced nursing programmes such as diploma and degree, eventhough nurses wanted to acquire more knowledge and upgrade their practice (Chong et al., 2014). Nsemo et al. (2013) argued that nurses are less likely to participate in continuing formal education programmes if the programmes did not meet their expectations and the qualifications obtained from engaging in such programmes could not be used in pursuing advanced programmes. The authors added that unavailability of online educational programmes also prevented nurses who could not leave their work place and residence to far reaching educational institutions from returning to school. Studies also indicate that nurses who are in school do encounter a lot of challenges whilst on a programme of study. For instance, Hutchinson, Mitchell and St John (2011) maintained that enrolled nurses who were admitted straight into the second year of the bachelor of nursing programme without going through the first year found the academic environment challenging, especially when they had to deal with writing skills, were not sure of what was expected of them as students and encountered difficulties getting information about their programmes of study. The authors further added that the enrolled nurses were not happy when their already acquired clinical nursing experience was not considered when they engaged in clinical sessions as students and were only allowed to partake in basic nursing activities when they felt competent to carry out complex nursing procedures. The student nurses recommended in the study that, they should be given the needed orientation about the university environment, what is expected of them as students as well as adequate support from faculty. Barriers which undermine nurses’ decision to continue their education may also originate from the healthcare facilities within which nurses work. In Jimma Township, South West Ethiopia, 30 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Fentahun and Molla (2012) performed a cross - sectional study of 319 health care professionals who are directly involved in clinical services at a public health facility to identify the determinants of and opportunities for continuing formal education. The findings of their study indicated that only 25% of the study participants participated in continuing formal education and that participation in continuing formal education did not steadily increase as working experience increased. 71.8% participants mentioned the lack of support from their current employer as the reason for not participating in continuing formal education. Health care professionals with a lack of support from management were 2.4 times more likely not to participate in advanced education. Also, health care professionals with the lack of resources other than financial were 2.2 times more likely not to participate in advanced education. In the same fashion, Ikenwilo and Skåtun (2014) confirmed that among the barriers which prevented doctors from enrolling in continuing formal educational programmes were insufficient organisational support and lack of cover. Sarver et al. (2015) also posited that lack of tuition reimbursement and time commitment deterred nurses from continuing their education. Lack of support from colleagues and nurse in - charges has also been identified as a major hindrance to nurses’ participation in continuing formal education. According to Shahhosseini and Hamzehgardeshi (2015), younger nurses asserted that they could not participate in continuing formal education programmes due to the fact that their senior colleagues at work did not prepare the duty roster to favour their participation in such programmes. Work overload was also another barrier which prevented nurses from participating in continuing formal education. Irrespective of the high workload of nurses, some nurses also complained of holding several appointments and being members of numerous committees which also gave them limited time to pursue continuing formal education programmes (Shahhosseini & Hamzehgardeshi, 2015). 31 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Shortage of nurses, organisational culture and leadership of institutions also hinder nurses’ decision to continue their education. In Coventry, Maslin - Prothero and Smith (2015) study to find out the impact of healthcare organisations supply of nurses and nursing workload on nurses participation in continuing formal education, the authors discovered that nurses did not engage in continuing formal education programmes as a result of lack of relief cover, shortage of nurses, difficulties in obtaining study leave and lack of time to participate in the programme. The nurses in their study had to use their personal time to embark on educational programmes. Another barrier which dissuades nurses from engaging in continuing formal education is the fact that leadership and organisational culture make it difficult for nurses who had pursued continuing formal education to implement the knowledge they had acquired from school. In a study conducted by Pool, Poell, and Ten Cate (2013) to find out the opinions of younger and older nurses on continuing formal education, the study showed that nurse managers preferred nurses who remained at the bed side to care for patients and learn on the ward through informal learning activities. The nurse managers were of the view that nurses who pursued continuing formal education programmes developed faster professionally and would not like to give direct care to patients but rather move on in life. On the other hand, Munro (2008) opined that differences in the individual nurses’ personal ambitions and the demands of the employer created tension at the work place when it came to continuing formal education for nurses and this sort of prevented majority of nurses from engaging in continuing formal education. Richards and Potgieter (2010) maintained that organisational environment which does not support the education of nurses makes it difficult for nurses to participate in continuing formal education. According to the authors, lack of articulated development plans on continuing formal education by organisations within which nurses worked, lack of funding to support nurses’ education, difficulties in obtaining study leave and lack of promotion for nurses who 32 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses had continued their education deterred nurses from engaging in continuing formal education. Pamela et al. (2013) also confirmed that nurses who were working and had enrolled in continuing education programmes could not complete their programmes of study due to the difficulties in balancing study demands with work. Dispositional barriers are known to prevent nurses from engaging in continuing formal education. Dispositional barriers are internal or psychosocial barriers that are related to the individual’s perceptions, attitude and expectations towards education. According to Richards and Potgieter (2010), a nurse experiencing a dispositional barrier may have a negative attitude towards school which may be as a result of horrible experiences with schooling, may not be concerned about returning to school and may lack the physical and emotional energy to keep up with schooling. The authors added that dispositional barriers may bring about nurses developing low self - esteem, low confidence as well as low aspirations and doubts about the importance of continuing formal education. Muliira, Etyang, Muliira and Kizza (2012) who measured the orientation of 200 nurses at the Uganda’s national hospital towards lifelong learning maintained that nurses’ negative attitude towards continuing formal education was linked to professional experience, age and educational level. As regards professional experience, many nurses who had not returned to school cited not needing a Bachelor of Science in Nursing (BSN) education to give good care to patients (Altmann, 2012; Orsolini - Hain & Waters, 2009). Sarver et al. (2015) also maintained that dispositional factors that hinder nurses from pursuing continuing formal education may include lack of computer skills and fear of online education. In a like manner, Schweitzer and Krassa (2010) sustained that negative experiences with continuing formal education programmes such as inexperienced teachers and a lack of order in the classroom had the potential of undermining the ability of nurses to pursue continuing formal 33 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses education. Hutchinson et al. (2011) also posited that, enrolled nurses who had started a bachelor of nursing programme confirmed inadequate preparation for school, difficulty adjusting to the academic environment as well as struggling to assume the role of a student was a barrier which made learning difficult. Dispositional barriers to continuing formal education may also include hostility towards school, no awareness of learning needs, lack of relevance of educational programmes, the belief that one is too old to learn and lack of confidence in one’s ability to learn (Shahhosseini & Hamzehgardeshi, 2015). 2.5 Measures to Enhance Continuing Formal Education of Nurses Cathro (2011) carried out a study to determine the factors which influence the decision of nurses to pursue graduate studies in nursing. A decision Matrix and Kurt Lewin’s Force Field Analysis were applied to the process of pursuing graduate studies in nursing education. The author identified the following creative strategies which can be put in place to support continuing formal education of nurses. The strategies included flexible programme delivery options, including more online graduate programmes; financial support, offering more programmes with a focus on nursing education, mentoring and collaborations between employers and academic institutions. Supporting the evidence of online learning as a measure to enhance continuing formal education of nurses, Karaman (2011) succinctly opined that generally, nurses have positive perception about online learning regardless of their age, working experience or area of residence. This is because online learning offers nurses the opportunity to pursue continuing formal education irrespective of their work schedules, personal responsibilities and the fear of returning to school. Although e - learning makes learning easier, accessible and faster, research points to the fact that it has its own challenges, as a result educational planners should deal with the challenges before blending e - learning into a programme of study (Lahti, Hätönen, & Välimäki, 2014). Gould, Papadopoulos and Kelly (2014) in their study to evaluate the suitability of e - learning 34 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses resources for the continuing formal education of midwives conceded that individuals responsible for e - learning programmes should take into consideration the needs of the different group of students whom the programme is designed for. The authors also opined that e - learning programmes should come with detailed instructions on how it will be used and how learning and competencies would be accessed, especially if the e - learning programmes would be used in different settings with different characteristics. Lahti et al. (2014) also indicated in their study that appropriately designed online programmes may enhance the continuing formal education for nurses, but nurse educators should ensure that in implementing online education, there is the need for technological infrastructure to be provided to support nurses who engage in it. Collaboration between stakeholders responsible for the education of nurses also brings about enhancement of continuing formal education for nurses. For instance, Fitzgerald, Beattie, Carter, and Caswell (2014) wrote a report about the successful nature of a part - time Baccalaureate of Science in Nursing (BSN) programme run by Nipissing University, Ontario, Canada for Registered Practical Nurses who were working on the ward. The authors indicated in their report that the success of the programme was as a result of the combination of online theory courses delivered through technologies and face - to - face clinical courses. The flexible nature of the programme permitted the students to easily balance personal and professional schedules with their studies. The authors also confirmed that through partnership between the programme manager, the clinical education leader, and the nursing faculty, students were supported to have their clinical at the same hospital where they worked so they could work and school at the same time. The authors concluded that the flexibility and accessibility of programmes in addition to a partnership among stakeholders of nursing education will lead to a significant increase in enrollment of nurses into continuing education programmes. 35 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Similarly, Brekelmans, Poell and Van Wijk (2013) conducted a study in Delphi using 38 Dutch experts including nursing employers, managers, educational institutions and professional associations to seek their opinions on what factors could be put in place to encourage registered nurses to participate in continuing formal education. The authors identified collaboration between all the stakeholders responsible for the education of nurses as a major factor that enhances nurses’ participation in continuing formal education. The reviewed literature points to the fact that for continuing formal education of nurses to be enhanced, the decision does not only comes from the nurse rather it requires the support of stakeholders who are responsible for the education of nurses. In addition, some studies advocate that stakeholders responsible for the continuing formal education of nurses could help promote the education of nurses by acknowledging the fact that the initial training received by nurses is not enough to sustain them through the practice of nursing. hence the need for the development of continuing formal education opportunities for nurses (Clark, Draper, & Rogers, 2015; Richards & Potgieter, 2010; Shahhosseini & Hamzehgardeshi, 2015). The literature also brings to the fore that in order to increase the attractiveness of continuing formal education by nurses, it is important that the educational needs of nurses are assessed and subsequently used in the effective planning and evaluation of programmes pursued by nurses (Eslamian, Moeini, & Soleimani, 2015; Nalle et al., 2010). In a study conducted by Chong et al. (2014) to explore current educational practice and future needs among seventy thousand registered nurses working in 178 ministry of health hospitals and community clinics in Malaysia, the study revealed that nurses were interested in specialist nursing topics such as cardiothoracic nursing, wound care management and cardiopulmonary resuscitation which was perceived to be an advanced practice. Comparatively, Ikenwilo and Skåtun (2014) in their study to identify the perceived needs of doctors in continuing formal education, found that doctors 36 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses were more likely to participate in continuing formal education programmes if the focus were on information technology, clinical training and management. The authors emphasised that rigorous attention to addressing the perceived needs of doctors is essential to the development of educational and training programmes which will be beneficial to their practice and profession as well as keep their knowledge up to date. In a like manner, Cynthia (2016) conceded that for the challenges surrounding registered nurses desire to go back to school for an advanced degree to be resolved, strategies are needed to help address issues regarding a commitment to degree completion, changing career paths, financial obligations and decisions about brick and mortar versus online learning. To her, the resolution of the above - mentioned challenges will enhance the chances of nurses in returning to school. Notwithstanding the fact that the needs of nurses should be highly considered in the designing of educational programmes for nurses, Pool, Poell and Ten Cate (2013) maintained that the needs of the different age group of nurses should be addressed. The authors opined that the different age level of nurses indicates there are differences in concerns relating to work and adult nurses may equate age to accumulation of much knowledge and experience as a result they might not be interested in continuing formal education programmes. In the same fashion, the authors were of the view that, continuing formal education programmes should have a purpose and level of focus. With regard, the purpose of educational programmes, the nurses in their study opined that educational programmes should be designed to train nurses who are competent and will remain on the wards or training programmes should be geared towards helping nurses progress to other aspects of the nursing profession be it academia, management and leadership. Furthermore, the authors sustained that educational programmes should have a focus because the majority of nurses are young and are still searching for what they really want to do or become in life, whilst adult nurses may be narrow - minded because they might have already created a niche for themselves. 37 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Pool, Poell, Berings and ten Cate (2016) in their study to find out the motives with which nurses engaged in continuing formal education discovered that nurses have different motives for participating in continuing formal education programmes. Nurses who wanted to develop their career participated in postgraduate education, whereas nurses who participated in conferences had the motive of deepening their knowledge. Some nurses also engaged in mandatory programmes because they had to meet some requirements. The authors recommended that nurses should be educated on these different motives anytime they want to pursue continuing formal education. Moreover, planners of continuing formal education programmes could also develop educational programmes to meet the different needs of nurses. Ross et al. (2013) confirmed the importance of educational planners adhering to the needs of the different age levels of nurses by emphasising the fact that issues surrounding generational differences of nurses and their different learning styles should be given the needed attention. In addressing issues regarding the different learning styles of nurses, Chong et al. (2014) advocated for innovative teaching methods such as self - directed learning, e - learning, evidence - based and problem based learning approaches to be introduced into classroom learning, to make education more easier and attractive to nurses. In highlighting the importance of measures to enhance the continuing formal education of nurses, Pamela et al. (2013) opined that continuing formal education programmes should be affordable, flexible, readily accessible and relevant to the nurse who wants to participate in continuing formal education programmes. [[[ The literature search also revealed that for continuing formal education to be made more desirable to nurses, basic nursing training education should be upgraded into tertiary education. For instance, Gao, Chan and Cheng (2011) reviewed thirty - four papers which included surveys, discussion papers, review proceedings, book chapters and one newsletter to examine the development of nursing education in the People’s Republic of China in its historical, 38 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses economic and socio - political context. The authors maintained that there was a need for secondary nursing programmes which are considered basic to be upgraded. They also recommended that nurses who were trained at this level are young and have lower educational background, consequently, the need for additional training to prepare these nurses to meet the increasingly demanding role of the professional nurse. The authors further opined that, although there were intense agreements to phase out the basic training of nurses, there continues to be an increase in enrolment into these programmes and again, the services of these nurses are needed in the rural communities, hence the need for the educational mobility of nurses to meet the demands of patients. In the same fashion, Rodrigo, Caïs and Monforte - Royo (2017) maintained that the need for well - trained nursing personnel in Spain to provide effective nursing care to citizens required that nursing education was upgraded to the University level. In as much as continuing formal education may be available, it is necessary that educational institutions put in measures to ensure nurses have access to equitable and relevant educational programmes (Duffy et al., 2014; Ross et al., 2013). Some researchers advocated that leadership of institutions within which nurses worked should assist nurses to continue their education (Coventry et al., 2015). Shahhosseini and Hamzehgardeshi (2015) in their study to find out the facilitators and barriers to nurses’ participation in continuing formal education concluded that nurse managers have a part to play in facilitating the continuing formal education of nurses. Similarly, Govranos and Newton (2014) maintained that ward managers and clinical nurse educators could facilitate nurses’ participation in continuing formal education by considering the characteristics of the adult learner, their values, beliefs, needs and potential barriers towards continuing formal education. The authors also encouraged ward managers to create an 39 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses organisational culture which promotes lifelong learning and continuing formal education among nurses. According to Munro (2008) creating an organisational culture that supports continuing formal education of nurses, requires that both the educational needs of the nurse and that of the organisations within which nurses work are considered by the two parties involved. The authors also recommended that employees positive and negative perceptions about learning need to be addressed in enhancing continuing formal education for nurses. Richards and Potgieter (2010) in their study to find out the perception of registered nurses working in four state health facilities identified some factors which could help organisations within which nurses worked to develop a culture of continuing formal education for their nurses. The authors argued that nurses’ development of interest in continuing formal education requires that, nurses within the organisation are valued, given the needed attention and are also respected. Secondly, nurses should be educated on career planning and management programmes. Thirdly, the authors recommended that senior staff members within institutions where nurses worked should take the lead in creating an organisational environment which promotes continuing formal education. The authors further encouraged management of healthcare facilities to draw staff development plans concerning continuing education and make it known to nurses during their annual review meetings so as to help nurses plan towards continuing education. Finally, the authors also opined that nurses should take their performance appraisals important as it would help managers and leaders know the learning needs of nurses and assist them to meet the identified learning needs. In addition to managers of healthcare institutions implementing measures to enhance the continuing formal education of nurses, Richards and Potgieter (2010) maintained that, continuing formal education should be considered as the responsibility of the employer and the nurse, where the employer is charged with the responsibility of providing training opportunities 40 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses for the nurse and also ensure that the nurse continues to maintain and develop her skills in the profession. The literature search further showed that for nurses to be interested in pursuing continuing formal education programmes there is the need for mentors to psyche nurses to develop a positive attitude to pursuing further studies. Skela - Savič and Kiger (2015) maintained that nurses need to be mentored by clinical nurses who engage in education and training programmes, research and have career development plans. Rouse and Rooda (2010) also recommended that for nurses to stay on educational programmes until completion there is the need for nurses to be given orientation on their programmes of study specifying the intensity and pace of programmes and students should be given assistance in developing a personal budget on how to seek financial assistance to embark on a programme of study. Also, there should be establishment of mentorship programmes where faculty can get the opportunity to support students and monitor their academic progress. Lastly, the authors recommended the need for counselling sessions to be organised for students to help them deal with stresses at school. [ 2.6 Summary of Literature Review The literature review focused on the perception, motivators and barriers encountered by nurses in their pursuit of continuing formal education. Literature was also reviewed on measures to promote the continuing formal education of nurses. The literature search showed that nurses have different perception about continuing formal education. Nurses’ perception about continuing formal education includes personal satisfaction, enhancing professional competencies, refreshing their perspectives about the profession, being abreast with current trends in the profession, exposure to different job opportunities, acquiring more knowledge as well as improving their care delivery skills. 41 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses The literature search pointed out that nurses are motivated to engage in continuing formal education because they want to be satisfied in life, enhance their professional status, elevate their level of understanding of the profession as well as update their knowledge. The literature further showed that flexible nature of educational programmes, organisational support such as flexible work hours, tuition reimbursement and influence of role models at the workplaces of nurses also influences their decision to pursue continuing formal education. Support from educational institutions to assist nurses to enroll in educational programmes and complete their study is another motivating factor. In addition, opportunities associated with continuing formal education such as promotion to the next rank, assuming leadership positions, exposure to research and critical thinking skills as well as support from family and friends are also identified as motivational factors which influenced nurses to return to school. In as much as some nurses may be determined to pursue further studies, the literature review indicated that there are barriers which make it difficult for nurses to realise their dream of returning for further studies. These barriers may arise in three forms which are situational, institutional and dispositional barriers. Situational barriers may include family responsibilities, pregnancy, financial difficulties in caring for one’s family whereas institutional barriers emanate from educational institutions and organisations within which nurses work. These barriers may include long distance to educational centres, stringent entry requirements, lack of information on available educational opportunities and the high cost of tuition fees. Barriers originating from the workplace of nurses may also include lack of tuition reimbursement, inadequate cover, workload, shortage of nurses and lack of organisational culture that promotes lifelong learning. The identified measures to enhance the continuing formal education of nurses include the need for all stakeholders responsible for the education of nurses to come together in promoting the education of nurses, effective assessment of educational needs of nurses and proper planning 42 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses to implement appropriate interventions to meet the needs of nurses, the need for more educational programmes especially specialty programmes which are affordable, flexible and can easily be accessed by nurses. Furthermore, the literature search emphasised the need for basic nursing programmes to be upgraded to tertiary level education to enable nurses with low - level education to be adequately prepared to meet the health care needs of patients. Also, there is the need for more innovative teaching strategies such as self - directed learning, evidence based and problem - based learning to be introduced into classroom teaching. Furthermore, the review of literature highlighted the need for mentors at both educational institutions and workplaces of nurses to mentor nurses to develop a positive attitude towards returning to school. Finally, the need for newly admitted nurses who enroll on educational programmes to be orientated on their programmes of study, academic expectations and the challenging learning environment was identified as a measure to encourage nurses to return to school for further studies. 43 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter describes how the researcher obtained data to answer the research questions. Areas covered include the research design, the research setting, the target population, sample size and sampling technique as well as tools and method for data collection. Data analysis, measures of ensuring methodological rigour, and ethical considerations are also highlighted. 3.1 Research Design The qualitative descriptive approach was used for the study. This designed is employed when a researcher seeks to describe a phenomenon, event or peoples’ experiences (Neergaard, Olesen, Andersen, & Sondergaard, 2009). This type of qualitative design allows the researcher gain insight into a phenomenon or experiences from the participants’ perspectives and describes events as accurately as possible and in a logical sequence depicting the meanings research participants’ ascribe to those experiences and events (Neergaard et al., 2009). In descriptive qualitative design the researcher answers questions such as what are the concerns of people about a phenomenon or an event. What are people’s responses concerning their attitude, thoughts and feelings toward an event or a phenomenon? (Sandlowski, 2000). The qualitative descriptive design offers the researcher the opportunity to stay close to the data obtained and the participants’ point of view, with the aim of providing a rich straightforward description of an experience or an event (Neergaard et al., 2009). Although the aim of a researcher using the qualitative descriptive design is to provide a rich understanding of the phenomenon under study, the researcher relies on a comparatively low level of interpretation to give insight into the phenomenon (Vaismoradi, Turunen &Bondas, 2013). The qualitative descriptive design allows the researcher the opportunity to present the findings of the study in 44 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses a simple everyday language which is similar to the informant’s language (Neergaard et al., 2009). The qualitative descriptive approach was appropriate for this study as it allowed participants describe vividly their personal experiences concerning continuing formal education and offered the researcher the opportunity to explore, understand and describe in details the experiences of non - professional nurses on continuing formal education in their naturally occurring settings. 3.2 Research Setting The research setting for the study was Pantang Hospital located at Pantang in the La Nkwantanang district in the Greater Accra Region of Ghana. The hospital is about twenty five (25) kilometres from Accra Central and is located on the Alafia road about one and half (1.5) kilometres off the Madina - Aburi Road. The hospital was established in the year 1972 by National Redemption Council Decree 30 and commissioned in 1975. Pantang Hospital being among the three largest psychiatric hospitals in Ghana caters for patients from all over Ghana and nearby countries such as Togo, Benin, Nigeria, Burkina Faso and Ivory Coast. The sole responsibility of the hospital is to provide mental health services to all persons with mental health problems. Other health care services provided by the hospital include medical outpatient care for all medical conditions, laboratory services, drug rehabilitation and psychological counselling services. The medical outpatient department is a polyclinic which operates for twelve (12) hours in a day, which means that patients requiring intensive care are referred to other hospitals for further management. The hospital has a five hundred (500) - bed capacity and is divided into ten wards (10) with fifty (50) beds each which caters for psychiatric patients. The wards are divided into six (6) male and four (4) female wards. Currently, one (1) of the female wards has been closed down 45 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses for renovation purposes. The hospital also has an anti-retroviral therapy unit and a maternity block. Although the maternity block is functional, it has no operation theatre as a result clients needing caesarian section are referred to other facilities for further management. The hospital can boast of three hundred and twenty - seven (327) staff members including one (1) psychologist, one (1) occupational therapist, three (3) medical doctors, one (1) psychologist and five (5) medical assistants. The hospital is also managed by nurses of all categories, including general and psychiatric nurses, community health and enrolled nurses. The hospital currently has five (5) community health nurses with their ranks ranging between senior community health nurses and community health nurses, as well as twenty - three (23) senior enrolled nurses and fifteen (15) enrolled nurses who work on the various wards. Currently, nine (9) enrolled nurses are on study leave with pay to pursue further studies. [ The researcher chose this setting because the Pantang hospital is located on the same premises with two nursing training colleges; which is Nurses’ training College Pantang and Post Basic Midwifery training school Pantang. Availability of these training schools makes it easier for non - professional nurses wishing to pursue further studies to do to so with much ease. Secondly, the proximity of the hospital to the researcher was another factor which motivated the researcher in choosing the Pantang hospital as the research setting. 3.3 Target Population Polit, Beck and Hungler (2001) define the target population as the total group of study participants whom the researcher is interested in studying. The target population for this study comprised all non – professional nurses working at the Pantang hospital. 46 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 3.3.1Inclusion Criteria a) Non - professional nurses who have worked for at least five years at Pantang hospital and have completed any form of continuing formal education. b) Non - professional nurses who have worked for at least five years at Pantang hospital and are currently pursuing continuing formal education. c) Non - professional nurses who have worked for at least five years at Pantang hospital and have not engaged in continuing formal education. d) Non - professional nurses who consented to be part of the study. These groups of non - professional nurses were chosen for the study because according to the Ghana Health Service policy on study leave, a non - professional nurse qualifies to pursue additional studies after working for five years after his or her initial appointment. 3.3.2 Exclusion Criteria a) Non - professional nurses at Pantang hospital who have not worked for five years. 3.4 Sample size and Sampling Technique Creswell (2007) defines sampling as the act, process or technique of selecting a representative part of a population for the purpose of determining parameters or characteristics of the whole population. In order to elicit rich information from study participants, the researcher conducted in - depth interviews with twenty - three study participants. However, the final sample size was determined during data collection when saturation was reached with the twenty - third (23) participant where research participants introduced no new perspectives on the topic under study and the new data collected did not make a further explanation of the phenomenon being investigated (Back, 2012). 47 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses The sampling technique for this study was purposive sampling. Cohen, Manion and Morrison (2005) posit that purposive sampling is the most appropriate non - probability sampling technique for qualitative studies. Purposive sampling method was used to identify and select non - professional nurses as per above description to give a detailed account of their experiences regarding continuing formal education. 3.5 Research Tool Data collection tools are designed to obtain data on a particular topic of interest. A semi - structured interview guide with open - ended questions based on the research questions, constructs of the conceptual framework and the reviewed literature were used as a tool for collecting data. The interview guide was in five sections. Section A focused on the demographic data of participants whereas Section B centred on perceptions on continuing formal education, Section C elicited information on motivating factors to continuing formal education, Section D identified the barriers to continuing formal education whereas Section E dealt with measures to enhance continuing formal education (See Appendix A). The semi - structured interview guide with open - ended questions granted the study participants the opportunity to give a detailed description of their experiences and also allowed the researcher to probe further when study participants were not giving answers which were in line with the research questions (Turner, 2010). The developed open - ended interview guide was pretested with some few selected non - professional nurses at Kwahu Government Hospital, Atibie in the Eastern Region of Ghana which has non - professional nurses with a similar characteristic like study participants. Kvalve (2007) explains that pre - testing the interview guide assists the researcher to know the strengths and weaknesses of his interview guide in terms of ambiguity of questions, leading or double barrel questioning and the duration 48 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses of the interview sections so as to make the necessary corrections in order to elicit the appropriate responses before using the data collection tool for the original study. 3.6 Data Collection The researcher obtained formal permission from the administrator and deputy director of nursing services of Pantang hospital to select research participants. This she did by presenting both the introductory letter and ethical clearance obtained from the School of Nursing and Midwifery and the Institutional Review Board at Noguchi Memorial Institute for Medical Research, University of Ghana, Legon respectively. Non - professional nurses in Pantang hospital were contacted by the researcher and briefed about the purpose and procedure of the study. The information sheet was also given for further clarification on the research topic. Non - professional nurses who met the inclusion criteria and were willing to participate in the study were given the consent form to sign, signalling their willingness to participate in the study. A convenient day, time and venue were set with each participant for the interview to be conducted. The researcher used a field diary to take note of all major happenings and non - verbal communication cues portrayed by study participants during the interviews. Important incidents that occurred with each interview session were documented in the field diary. The researcher ensured that the audio recorder was functioning well and fully charged for each interview session. Before the interview section commenced, the researcher established rapport with participants to allay their anxiety by talking generally about continuing formal education. The researcher informed participants about her intentions to record the interview section; this enhanced the capturing of accurate information, thus increasing the potential of acquiring credible and detailed information. 49 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Participants were encouraged to ask questions to clear any doubts before the interview section started. Data were collected through face to face interviews during which participants were encouraged to relax, feel free and express their thoughts and feelings. The researcher used probing questions to help participants contribute meaningfully to the discussion. At the end of each interview session, the researcher played back the recorded interview to each participant to ensure that all important data had been collected. The recorded interviews were then labelled and listened to severally to make meaning out of the interviews and also aid in transcription of the data. The field diary was then read and re - read to align the written notes with each interview’s recordings. [ The researcher certain of data gathered then transcribed verbatim the interviews. The transcribed data were read and re - read looking for phrases, keywords and statements. The researcher also made reflections on what happened, why particular incident took place and how it actually did happen. Finally, all the activities of the day with regard to the interview were summarised after which modifications and adjustments were made to improve upon subsequent interviews. Saturation was reached in the data gathering process with the twenty - third participant as no new perspective concerning the topic under study was obtained. All information from participants were kept safe. A file was opened with the various aspects of the interviews and all appropriate documents such as the signed consent forms, demographic data and field notes made during the interview sections filed. The audio recordings were also stored on hard drives and kept safe electronically. 3.7 Data Analysis Data were analysed using thematic content analysis. This technique allowed the researcher to disintegrates the text into relatively small units, looking for trends and patterns of words, their frequency and relationships so as to give a detailed description of the data (Vaismoradi, 50 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Turunen, & Bondas, 2013). In using the thematic content analysis in analyzing the data gathered from study participants, the researcher first had to familiarize herself with the data by listening to the audio recorded interviews several times to become conversant with its contents, understand it and make meaning of each interview. The data were then transcribed, read and re - read to know the depth and breadth of what the data entails. As the data were read carefully, interesting ideas in the data were highlighted to assist the researcher in her analysis. The researcher after reading the entire data set then treated each interview’s transcript as a whole document. Unit of analysis of data was carried out by examining line by line of each sentence of all the data set to inductively generate codes that capture the meaning and content of each sentence. After identifying all the codes emerging from these sentences, the codes were compared with the original data to see whether the codes reflect or are congruent with the data. The identified codes were then analysed to find out how different codes support each theme guiding the data analysis. This the researcher did by considering the relationship between codes, their similarities and differences to form sub - themes. The themes guiding the study and the identified sub - themes were correlated with the entire data set (Braun & Clarke, 2006). Codes that did not appear to fit into the themes and sub - themes were also noted. The themes, sub - themes and all the extracts of data that were coded with pseudonyms of study participants were organised using the Nvivo11 software for analysing qualitative data. The researcher after developing the themes and sub - themes of the study reflected on the commonalities and differences of the identified themes and sub - themes, their collated data extracts in relation to the content of the data sets and analysed how they conform to the research topic, research questions and the purpose of the study. Finally, a detailed report of the results of the study was written, highlighting the study’s findings and supporting them with verbatim quotations from study participants. 51 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 3.8 Data Management All information obtained from study participants during the interview sections such as the date, time and place were jotted in the field diary. Transcripts of data for each participant were numbered, given pseudonyms and were appropriately filed. The demographic data, as well as the individual consent form for each participant, were also filed. The transcripts, audio recordings and field diaries have been kept safe electronically with only the researcher and supervisors who could get access to it. 3.9 Rigour of the Research The rigour of a study demonstrates the criteria and standards that are used in evaluating the overall significance, relevance, impact and utility of a completed research (Morse, Barrett, Mayan, Olson & Spiers, 2002). The researcher used Lincoln and Guba (1985) criteria in ensuring the rigour of the research. Lincoln and Guba came out with four criteria for determining the trustworthiness of a qualitative research. They include credibility, dependability, transferability and confirmability. According to Shenton (2004), the credibility of a study is the researcher’s ability to demonstrate that her research methodology measured what it purported to measure. The researcher ensured the credibility of her study by selecting the appropriate research methodology and design for the study. The qualitative descriptive design was used to explore, understand and describe the lived experiences of non - professional nurses regarding continuing formal education. The researcher also established early acquaintances with non - professional nurses by making visits beforehand to the population of non - professional nurses and also reviewed appropriate documents to know much about the target group and their experiences regarding continuing formal education. 52 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses The purposive sampling technique was also employed in selecting study participants who met the inclusion criteria, were representative of the population and were also prepared to give adequate information that answered the research questions of the study (Morse et al., 2002). Informed consent of participants was also obtained as participants were briefed on the purpose of the study. Individuals who showed interest to participate in the study and freely share their experiences with the researcher became study participants. Participants were also assured of the confidentiality of their information and this helped them to freely open up with their experiences concerning continuing formal education with the researcher. [ During the interview sections, the researcher used open ended questions and probing questions to elicit detailed information from the research participants. The researcher further maintained frequent debriefing sessions with her project supervisors to interact with them regarding the research methodologies and the data gathering procedures so as to obtain their perception on the topic under study. This, in turn, helped the researcher to identify flaws in her work and the necessary corrections made. The researcher again engaged in peer scrutiny of her work by presenting her research work to colleagues, academics and peers as this helped the researcher to receive feedback so as to make the needed corrections in her work. The researcher also employed member checks by verifying with the study participants whether the transcribed data represented their ideas or what they intended to share with the researcher (Lincoln & Guba, 1985). Finally, the researcher also found out as to whether or not her research findings or the themes that emerged from the study were in consonance with the findings of previous studies (Shenton, 2004). [ The second criteria the researcher used in establishing the rigour of the study is dependability. Dependability in qualitative research explains the extent to which the research methodology 53 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses when repeated with similar participants will yield similar findings (Lincoln & Guba 1985). The dependability of the study was maintained by describing in details the research methodology under which the research was carried out. The detailed description of the research methodology would offer readers of the study the opportunity to assess how far the researcher followed the approved guidelines for conducting the research as this would pave the way for future researchers to repeat the study. The researcher again explained the data gathering process into details, elaborating on what really took place on the field, the duration involved in the data collection. The third step employed in ensuring the trustworthiness of the research was transferability. This refers to the extent to which the research findings can be applied to individuals and situations with similar characteristics as that of the study. In order to achieve this, the research setting which is Pantang Hospital was explained in detail for readers of this research to apply the research findings to similar contexts. The researcher further provided sufficient deep descriptions of the topic under study so as to aid the reader’s understanding and application of the research findings to similar circumstances or situations. The researcher also gave a detailed description of the research participants, stating categorically the inclusion and exclusion criteria of study participants. [ The last stage in ensuring the rigour of the study was confirmability, which is the extent to which the research findings reflect the views and experiences of the study participants and not that of the researcher. The researcher enhanced confirmability of the study by applying bracketing. This, the researcher did by ensuring that all her preconceptions and early acquaintances with some non - professional nurses she had worked with on the ward did not influence on the findings of the study. The researcher explained in detailed her decision for choosing a specific research methodology and conceptual framework guiding the research. 54 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Finally, the researcher verified from study participants whether the transcribed data represented their ideas or what they intended to share with the researcher. 3.10 Ethical Consideration Ethical consideration for a research is concerned with obtaining informed consent and maintaining the confidentiality of individuals who participated in the study. Ethical approval for this research was obtained from the Institutional Review Board at Noguchi Memorial Institute for Medical Research at the University of Ghana, Legon. An introductory letter was also acquired from School of Nursing and Midwifery, University of Ghana, Legon and given to the administrator of Pantang hospital where the study participants were recruited. The researcher booked an appointment with non - professional nurses, established rapport with them and the nature, purpose, procedure and the importance of the research was verbally explained to them to aid their understanding of the research. The researcher ensured that the participants were given the information sheet for about a week to read and decide whether they would participate in the study or not. The study participants were also given the opportunity to ask questions about the research to clear any doubt or misunderstanding they had. Selection of participants was based on voluntariness and no coercion was applied. Participants were also given the opportunity to withdraw from the study at any point in time without any consequences. Non - professional nurses who agreed to be part of the research were given the informed consent sheet to fill and append their signatures. They were also assured of confidentiality with respect to their identity and the information provided. During data analysis, pseudonyms were used in identifying participants. The information given was solely for academic purposes. Only the researcher and her project supervisors had access to the information collected. The audio recordings and the transcribed data were stored on hard drives and kept safe electronically. The field diary was 55 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses also kept under lock and key. Snacks were provided to refresh participants after the interview session. 56 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses CHAPTER FOUR FINDINGS OF THE STUDY 4.0 Introduction This chapter describes the findings of data that were generated from the participants in this study which intended to explore the experiences of non - professional nurses at Pantang hospital in the Greater Accra Region on continuing formal education. Twenty - three study participants were engaged in the study: they include (1) non - professional nurses who had completed continuing formal education. (2) non - professional nurses who had enrolled in a continuing formal education program and (3) non - professional nurses who had not engaged in any form of continuing formal education. Four main themes guided the study with their corresponding sub - themes that emerged from the data. The main themes and their sub - themes are presented with anonymised verbatim quotations from the participants using pseudonyms. The main themes were in harmony with the constructs of Cross Chain of Response Model (Cross, 1981) and the objectives of the study. Data have also been presented to express the views of the three groups of participants involved in this study. The main themes were: (1) Perception of continuing formal education. (2) Motivational factors for pursuing continuing formal education (3) Barriers to continuing formal education (4) Measures to enhance continuing formal education (See Appendix D). The data obtained from participants were presented in agreement with the objectives of the study which were to:  Explore the perception of non - professional nurses on continuing formal education.  Evaluate the factors that motivate non - professional nurses to pursue continuing formal education.  Examine the barriers to continuing formal education encountered by non - professional nurses. 57 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses  Identify measures that would promote the continuing formal education of non - professional nurses. 4.1 Demographic Characteristics of Participants Twenty - three (23) participants were interviewed for the study. Twenty - two (22) were females and one (1) male. Six (6) had completed continuing formal education. Out of the six (6), one (1) had graduated with Bachelor of Science in Nursing; one (1) had also obtained Diploma in Health Promotion, two (2) with Diploma in Community Psychiatry and two (2), in Certificate Post Basic Midwifery. Nine (9) of the participants were also pursuing continuing formal education. With the nine (9), eight (8) had enrolled in Certificate Post Basic Midwifery and one (1) in Bachelor of Science in Nursing. Eight (8) of the participants had not engaged in continuing formal education after their initial training as non - professional nurses. The age range of participants was between twenty – nine (29) and thirty – seven (37) years; with a modal age of twenty – nine (29) years and an average age of thirty (30) years. Fourteen (14) of the participants were married whilst nine (9) were single. The participants who were married had at most two (2) children who were aged between eight (8) months and five (5) years (Refer to Appendix C). 4.2 Perception of Non - Professional Nurses on Continuing Formal Education An individual’s perception about continuing formal education will influence his or her decision to either enroll in a programme of study or not. In answering the first research question on how non - professional nurses perceive continuing formal education, the main theme “perception of continuing formal education” with four sub - themes were identified. This theme explains the fact that majority of non - professional nurses perceive continuing formal education as essential to their professional and personal growth, hence the need to be given the opportunity to pursue continuing formal education. All the participants considered continuing formal education to be important to their profession. Participants who are in school regarded continuing formal 58 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses education as offering them the opportunity to engage in intensive learning for a longer duration where they have much time to learn what is being taught and acquire a higher or an additional certificate upon completion. Participants viewed continuing formal education as essential to nursing practice due to the dynamic nature of the profession. All the participants perceived continuing formal education as a medium to acquire more knowledge about the nursing profession, learn new things, broaden their knowledge, enhance their professional competencies and skills as well as keeping abreast with current trends in nursing and the world. The participants also considered continuing formal education as helping them acquire skills that will help them improve the care given to patients. Participants reckoned that returning to school would help them understand the rationale behind nursing practice; they would be able to assess the needs of their clients, advocate for their health thereby enhancing clients’ satisfaction. [ All the participants believed that the higher academic qualification obtained from participating in continuing formal education programmes will enhance their promotion to a higher rank which obviously is linked to an increase in salary. Economically, all the participants were of the view that once they gain more knowledge, they could impact good health on their patients, family and the nation at large. Participants held the view that, an increase in salary implied they could take good care of their families as well as provide quality education for their children. [ The sub - themes that emerged from this theme were the acquisition of additional knowledge and upgrading; improvement in care delivery, impact on knowledge and practice, exposure to current trends in the nursing profession and raised economic standard. 59 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.2.1 Acquisition of additional knowledge and upgrading All the participants perceived continuing formal education as a means of furthering their education to acquire more knowledge and skills as well as upgrading themselves in the nursing profession. Lizzy who has completed a continuing formal education programme stated that: “I regard continuing formal education as a medium to get more knowledge, further my education and upgrade myself in the profession” Faustina who has not engaged in any form of continuing formal education also said that: “I perceive continuing formal education as going to school to acquire more knowledge and skills to my basic knowledge and upgrading myself in the nursing profession”. Additionally, all the participants held the view that the knowledge they acquired from their initial training as non - professional nurses is basic therefore the need to upgrade themselves. Sheila who had not engaged in any form of continuing formal education stated that: “With the health assistant clinical programme, all the courses we studied were titled Basic! Basic! Basic! E.g. Basic anatomy, Basic physiology and this affect the care we give to our clients because on the ward we practice without knowing the rationale behind it”. Doris who had completed a continuing formal education programme affirmed Sheila’s assertion as: “I went back to school because, as non - professional nurses what we were taught initially at school was basic knowledge, we were only trained to assist the professional nurse in the performance of her duties” Participants who are in a school maintained that having worked for sometime after their initial training, their already acquired knowledge and skills become obsolete, as a result, they need to acquire additional knowledge. Cynthia who has completed school stated that: “We are just like machines, when machine works for a while, it breaks down and needs to be repaired, and likewise as we work for a while, we lose the knowledge we have, so we have to go to school to improve on our knowledge, upgrade ourselves and catch up with the global world. At a point in time, we can no longer apply the basic knowledge we have” 60 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Lizzy who has also completed a continuing formal education programme and is currently enrolled in a distance programme shared her perception about continuing education as: “If you do not educate yourself, with time you lose all your knowledge, you feel you have become blank and don’t know anything” All the participants recounted that acquiring additional knowledge from participating in continuing formal education meant that they had the chance of obtaining a higher certificate in life which would help them pursue advanced programmes. Kezia who had not engaged in continuing formal education opined that: “I want to further my education because I have a basic certificate in nursing. I want to pursue diploma and even follow it up with first degree and masters in the future” Doris who has completed school also said that: “I regard continuing formal education as going back to school to learn and acquire a higher certificate or additional certificate. Acquiring a higher certificate serves as a stepping stone to pursuing advanced programmes like public health nursing” Participants who have completed school and those currently on a programme of study argued that continuing formal education is different from in - service training (workshops) and offers nurses much time to learn and acquire more knowledge. Rose who is currently pursuing a post basic midwifery programme acknowledged that: “Workshops cannot be compared to continuing formal education; they are being compressed or are limited in nature but continuing formal education offers the nurse a longer duration to learn so many things” Naomi who has completed school also expressed her view as: “Continuing formal education is better than workshop because the things you will learn within one year at school, Workshop will use only a week due to lack of resources and the nurse may not capture all the salient points being taught”. 61 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.2.2 Improvement in Care Delivery In general, all the participants acknowledged that by engaging in continuing formal education, they could acquire knowledge that would enhance their delivery of quality of care to their clients. Eugene who has engaged in continuing formal education to become a health promoter had this to say: “Continuing formal education affects the care one gives to his client, the health promotion I studied at school helped me to study the community members to know their problems which they may not be aware of and I help them solve it” Doris who now holds a Bachelor of Science in general nursing also expressed her views as: “In community health nursing, we studied obstetric nursing but I did not understand so many things. Personally, continuing formal education has helped me know the rationale for history taking, why it is important to take the family and medical history of clients. Acquiring this new knowledge has made me understand my work and appreciate what I do” In a like manner, participants who have completed continuing formal education and work within the communities and villages are of the view that, the knowledge acquired from school would help them to do their preventive nursing work well thereby reducing the pressure on our hospitals. For instance; Naomi who has completed school expressed her opinion as: “I love the community nursing work because when I educate my clients to wash their hands after visiting the toilet, not to put their hands on the floor, sleep under insecticide treated net and exclusively breastfeed their babies, they would not fall sick and the curative nurse would not get much work to do thereby reducing the burden on our hospitals” Participants who are pursuing continuing formal education programmes to become midwives hoped that through their education they would help curb maternal and infant mortality. Rachel who is currently in school sustained that: “By acquiring new knowledge at school I will come back to contribute to the work. I believe that, after school, I can help in reducing maternal and infant mortality” 62 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Participants who are currently in school perceived improvement in the quality of care of patients as enhancing client’s satisfaction. Loretta who is in school maintained that: “At my facility, we always record a low number of antenatal attendants; this is because we are not midwives. With regard to palpation and examination, we resort to “trial and error” and this affects our work, majority of our clients are not coming for antenatal services, when they compare our services to that of other facilities, they are not motivated to come back to us, this sort of pushed me to upgrade in midwifery to improve the quality of care of my clients” Generally, all the participants perceived continuing formal education as having a greater impact on knowledge and practice which leads to improvement in care delivery. Participants felt that once they are educated, they could pass on the knowledge they have acquired to colleagues and the upcoming generation of nurses. Charlotte who has not enrolled in any continuing formal education programme shared her perception as: “I believe furthering my education will influence my nursing care and help me impart knowledge on my colleagues and the younger generation of nurses” Sheila who has not returned to school emphasised Charlotte’s assertion as: “As you grow in your job, you become a senior and get the opportunity to impart knowledge to the younger generation. The only way to teaching colleagues, students and newly qualified nurses to maintain the standards of nursing practice is by furthering your education” 4.2.3 Exposure to current trends in the nursing profession All the participants perceived continuing formal education as exposing them to current trends in the world and broadening their knowledge about the nursing profession. Some participants maintained that living in a technological era requires that non - professional nurses continue their education so as to meet the standards of nursing practice. Kezia who has completed a continuing formal education programme had this to say: “We live in an ever changing world which is advancing in technology, so there is the need for one to stay abreast of current trends in nursing, if not 63 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses one will be left behind or when confronted with a new challenge, it will be difficult not to know how to tackle it” Jennifer who is in a school maintained that: “Continuing formal education is good, we are now advancing in technology as a profession and so everybody needs to explore. Now the world is changing and things are being upgraded, as a result, we need to go to school and acquire new knowledge so that we will do away with some old practices we used to perform” Non - professional nurses who have completed continuing formal education programmes maintained that continuing their education exposed them to different programmes in the health sector. Lizzy who is in school shared her sentiment as: When I got study leave to pursue diploma I thought, that was the highest qualification in academia, but at school, I realised some of my seniors were pursuing their first and second degrees; believe you me that was the first time I heard about these programmes” 4.2.4 Raised Economic Standard All the participants agreed that engaging in continuing formal education leads to enhancement in salary. Sandra who has not engaged in continuing formal education expressed her opinion as: “Everyone works because of money. All the work we do is about money. Nurses with first degrees and masters receive a better salary than me so I have to go back to school so that I can also earn more salary” Eugene who has completed school also stated that: “The health system makes you broke, so as a man you need to upgrade yourself so as to have an increase in your salary” An increase in salary was also linked to the fact that continuing formal education comes with promotion to a higher level in the nursing profession. Ruby who is in school opined that: “My salary is not enough, by furthering my education, I will be promoted to a higher rank and it will bring an increment in my salary” 64 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.3 Motivational Factors for Pursuing Continuing Formal Education Motivational factors give reasons for a person’s actions, needs and desires. The motivation to carry out an act may come from within the individual or forces external to him or her. In this study, the factors which motivate non - professional nurses to continue their education originated from their working experiences, interaction with colleagues at the workplace and the general public. In analysing the data, the main theme “motivations to continuing formal education” and eight sub - themes emerged from the data. The sub - themes included self - determination, low academic qualification, progression in life, employer’s recognition of higher academic qualification than experience, lack of professional competencies and skills, ambition and drive for better career options, lack of respect and influence of mentors and role models. Participants in the study were motivated to further their education because they were self - determined. They believed that upgrading one’s knowledge in the nursing profession is a necessity hence their determination to do everything possible to continue their education. Particularly, participants who are in school felt it is their responsibility to advance in knowledge. Another motivating factor that emerged from the data is the fact that participants considered themselves youthful and ambitious as a result they could excel to greater heights. Low academic qualification of participants is also a major motivator to returning to school. All the participants in the study held the opinion that their low academic qualifications made them deficient in the practice of nursing. The majority of participants also wanted to continue their education because they practised without knowing the rationale behind what they did. Others felt they needed to build on their professional competencies. Furthermore, participants acknowledged that they were least respected in the nursing profession, hence the need to continue their education to gain respect. For instance, participants 65 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses did not like to be called auxiliaries or nurse assistants. In addition, humiliations and insults from superiors as well as lack of recognition for work done also influenced participants’ decision to return to school. A few of the participants did not like the position of their names on the duty roster, thus the need to go back to school to acquire a higher qualification. Participants who have completed school and those currently on a programme of study were motivated by role models and the contributions they made to the nursing profession. Finally, participants who were in school sustained that, they did not want to remain auxiliaries forever and desired to be midwives, establish maternity homes as well as becoming public health nurses. Responses from participants explaining the various sub - themes are presented below. 4.3.1 Self - determination Participants who have completed school and those in school were personally determined to continue their education as they felt they had the right to education, were youthful and full of capabilities. Eugene who has completed school shared his motivation as: “I was personally motivated to go back to school. After completion of my basic certificate programme, I was in my early twenties so I told myself that I had to go back to school within the next three years, I improved on my senior high school grades and pursued diploma in health promotion” A number of participants who had completed their education felt they were still young in the profession so could do more for themselves. For instance, Doris who now holds a Bachelor of Science in Nursing had this to say: “After working for 5 years at the CHPS compound I realised I could do more for myself considering my age and intelligence level; I could not stay as a community health nurse forever and be regarded as an auxiliary, therefore I enrolled in a remedial classes to better my grades. This was not easy because I had to be commuting from the village where I worked to the city for classes but with determination, I passed the exams successfully” Participants who have completed school and those who have enrolled in a programme maintained that the academic environment was full of pressure, but they were determined to 66 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses sail through their programmes of study despite the challenges. Victoria who has completed school shared her experience as: “Before I went to school, I was told the programme was difficult. I got to school and realised it for myself, the first year was not easy; but with determination, I told myself I would complete this programme” Loretta who is on a programme of study had this to say: “The brain has been dormant for some time and this makes learning difficult but with determination, I know I can complete the programme” Additionally, a number of participants who are in school iterated their determination to complete their programmes successfully by trusting in God. Ruby who is pursuing post basic midwifery affirmed that: “The programme is not easy, am going through pressure because I have no care taker assisting with the family chores and this makes learning difficult, but I trust in God and I believe he will see me through this programme successfully” 4.3.2 Low Academic Qualification All the participants were motivated to further their education because of their low academic qualification in the nursing profession. Non - professional nurses who are in school were motivated to continue their education because they are ashamed of their academic qualification. Lizzy who has enrolled on a programme of study narrated her experience as: “I used to work with plan Ghana ... At that facility, visitors came for visit from the United Kingdom and Canada. And it was like they were interested in knowing my academic qualification; I was ashamed of my qualification so it pushed me to go back to school” Rose who is also in school confirmed that: “Do you know that some private institutions in this country do not employ us because of our low academic qualification, sometimes you go for interviews at these hospitals and you are turned down? So obviously you will be motivated to go back to school” Participants who are engaged in continuing formal education lamented that their low academic qualification required that they worked under supervision even though they have the 67 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses competence. Lizzy shared her sentiments as: “On the field, you believe you have the skill to carry out a particular assignment, but because your qualification is low, you still have to be supervised and I hated this when you know you have much skill than the one supervising you. So I made the decision to go back to school” Despite the fact that some participants worked under supervision as a result of their low academic qualification others were prevented from undertaking some procedures and for participants, this is quite humiliating. Naomi who has completed a continuing formal education programme shares her experience as: “With all the skills we possess from our working experience, you are sometimes denied the opportunity to carry out some tasks on the field just because you hold a basic certificate and this is really humiliating” Participants are also suppressed on the ward due to their low academic level. For instance, Victoria who has completed a continuing formal education programme declared that: “Because of our low academic qualification, you will have the experience to practice but people would want to suppress you. So you have to also go to school” 4.3.3 Progression in Life Participants were motivated to engage in continuing formal education because they wanted to progress in life. Participants wanted to take advantage of all the opportunities life has to offer rather than being static in life. Charlotte who has not engaged in continuing formal education asserted that: “I am not comfortable with my level in the profession, I can’t just be at one place and be working, I need to move on in life. I believe there are several opportunities out there waiting to be explored” Doris who has completed a continuing formal education programme also had this to say: “Living in the village delays your plans, especially marriage and your boyfriend might even neglect you. The village life was not conducive for family life and all these affected me so I needed to readjust my thinking to move to a greater height” 68 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.3.4 Employers’ recognition for higher academic qualification than experience Generally, all the participants were motivated to further their education because they realised the health sector recognises advanced educational qualification for practice rather than years of experience. Kezia who has not enrolled in continuing formal education expressed her feelings as: “After working for six years on the ward, someone will come with a higher qualification with no experience, you will be teaching the person what to do, but that person will become your boss, so why don’t you also upgrade yourself to come and take that position” Victoria who has completed school also added that: “I went back to school because, in nursing, experience is not recognised. It is your qualification that will be used for your promotion to the next rank, even with my experience on the field; a new person with a higher certificate will become my boss” A number of participants who had not returned to school felt that irrespective of their years of working experience, suggestions made by them on the ward are bluntly ignored. Portia who currently works on the ward and has not pursued further studies lamented bitterly as: “Sometimes on the ward, a case will come up and you will give suggestions as to how best the case should be handled, but because you are a junior you would not be listened to. The senior nurse will try hers if she does not succeed; she now turns to you for your advice. At times it will be too late and a life might be lost” Stella who is currently in school also narrated how a small girl lost her life as a result of the low academic qualification she possessed: “During one clinical section, I saw a four - year - old girl with burns on the left thigh and in pain. I suggested how this could be managed effectively to the ward in - charge but because I was a nurse assistant I was brushed over… with time the girl’s burns got infected and she died. This story really hurts me. If the in - charge had listened to me, that child would not have died so I am motivated to learn hard and complete my programme so as to help save more lives” 69 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.3.5 Lack of professional competencies The majority of the participants were motivated to further their education because they believed continuing formal education would enable them to build on their professional competencies. Some non - professional nurses acknowledged that even though they were doing well with the practical aspect of nursing, they had some deficiencies in their nursing skills which they needed to build on. Sheila who is currently on the ward and had not engaged in continuing formal education shared her motivation to continue her education as: “When I came to the field, I did not know how to set an IV line and pass a catheter. Although I think am now doing well with the practical aspect of nursing, I believe that when I further my education, I will on build it and enhance my practical skills” Lizzy who is on a programme of study also maintained that: “As a community health nurse, I was supposed to do everything. Aside the weighing, immunisation and health education which I did without supervision, when it comes to conducting deliveries, I feel I do not have much skills and this could affect the lives of my patient, so I decided to further my education ” 4.3.6 Ambition and Drive for Better Career Options All the participants declared they were motivated to return to school because they had personal ambitions to attain in life. Others also recounted that their low educational background would not lead them to better career options, they would always remain auxiliaries, hence the need to further their education to access other career opportunities. Charlotte who works on the ward and has not enrolled in any continuing formal education programme asserted that: “For me, I want to aspire higher. This wasn’t my aim, that wasn’t where I wanted to start from. For me I want to pursue midwifery, specifically bachelor’s degree in midwifery and this has been my dream” Yvonne who has also not pursued continuing formal education averred that: 70 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “I want to become a public health nurse. On the ward, I don’t really like those yearly changes of working on the medical ward, then the following year, you are asked to go to a different ward which you might not be interested at working, so I want to pursue diploma in general nursing then after working for three years I will go on to pursue public health nursing” A number of participants who worked as community health nurses wanted different career options as their work was difficult and stressful and some worked for long hours alone without any assistance. Cynthia who had completed school remarked that: “I worked at the CHPS center alone with an orderly; in the mornings, I do consultations and around 12pm when the place is less busy, I close the centre and go for home visits looking for child welfare clinic defaulters, family planning defaulters as well as tracing the aged with wounds to dress them. I return to the facility and there will be clients waiting to be attended to. I rarely had time to eat. So I decided to go back to school to become a psychiatric nurse which I believe is more flexible” Additionally, Naomi who is in school lamented that: “The work was too laborious, through a polio immunisation exercise, I had a miscarriage, and it was my first baby so I made the decision to further my education so that I will look for a better career option” Participants acknowledged that the challenging physical situations such as working in rural areas with limited social amenities are factors which motivate them to pursue further studies so as to look for better career options. Eugene who has completed school and works within the community shared his experience as: “At the village where I worked, before pursuing further studies, there were no lights, places of convenience and washrooms; In fact it was a real ghetto so I advised myself to continue my education so that I could get a better career option” Some participants who work in remote villages complained of how the village life affected their personal development hence the motivation to further their education, acquire a higher certificate and look for a better career option. Rachael who is in school opined that: “You hardly stayed at one village for long, after two years of service you are certain that you will be posted to another remote village and this 71 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses affected us in so many ways, we could not plan our lives. So for me the best thing to do was to go back to school, get a higher qualification and move on in life” On the other hand, the unfair treatment meted out to participants at their workplaces motivated majority of participants to return to school so as to look for better career options. For instance, Kezia who works on the ward and has not engaged in continuing formal education declared that: “At work, we are mostly made to work on weekends; we do not get the chance to go to church. Sometimes you feel you are not being treated fairly so you have to also go to school to become a senior person to be able to enjoy other privileges” Victoria who has completed school also narrated that: “I assumed duty with a professional nurse, after three years we were all expecting our promotions, hers came and I was told my will come after five years. My sister in fact I felt very cheated, so I decided to further my education to become a professional nurse” 4.3.7 Practicing outside one’s Job Description Non - professional nurses were trained to assist professional nurses, but they found themselves carrying out the duties of the professional nurse. Practising outside one’s job description was a major factor which motivated participants to pursue continuing formal education. This makes them uncomfortable as they realize that it’s illegal and they could land in trouble. Loretta who is currently in school narrated her experience as: “Majority of non – professional nurses are not midwives, but we have been performing the role of midwives without having any license, so it is important you go to school and pursue midwifery so that you can also practice well” Similarly, Susan who works on the ward and has not returned to school stated that: “We worked outside our job description. My job is to only assist the professional nurse, I am not supposed to give medication but I do all that” Stella who is in school affirmed that: 72 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “On the job, you are forced to do things which are not within your job description and when problem comes, you fall in trouble and you are humiliated” Although some participants knew the consequences of practising outside their job description, they always considered the plight of their patients. Faustina who had not pursued continuing formal education corroborated that: “I know I am to assist a senior colleague on duty, but sometimes you are only two non - professionals on a shift and there is no senior nurse or a doctor. If a the patient has to be fed you have no option than to pass a nasogastric tube for the patient but this is not my duty” 4.3.8 Lack of Respect Lack of respect experienced by participants was a major factor which motivated non - professional nurses to continue their education. Professional nurses and other health care professionals disrespected the non - professional nurses. Other participants also felt humiliated by the general public. Ruby, for example, narrates how she was motivated to go back to school: “I wanted a change of job title from a community health nurse to a midwife and this comes with respect because when you are in the brown uniform, people believe you are not a good nurse. I felt my identity was at stake”. Mercy who has not been to school added that: “It feels like community health nurses are perceived as inferior, we are not respected at all within the health sector” The lack of respect experienced by participants was not limited to the workplace, non - professional nurses who are pursuing post basic midwifery lamented how they are disrespected by colleagues who are been trained as professional midwives at school Jennifer opined that: “Even at school we are not respected by our diploma colleagues, they think we are weak in knowledge. Can you imagine 17 and 19 years old students humiliating us because they believe we do not know anything?” 73 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses A number of participants felt that their work was not appreciated by their senior colleagues. Doris who had completed school narrated her ordeal as: “Personally, I made the decision to go to school when my superiors threw away my hard written report which I was going to submit at the district office” Naomi who has also completed school attested to what Doris said as: “I worked in remote villages which sometimes I would have to walk for one hour forty minutes while carrying the items I will need to work with. You are at times beaten by rains but our superiors humiliated us if we did not meet our target for the month. Out of this hard work, if you are not appreciated it really hurts” Participants who worked within the communities also narrated how the general public did not regard them in spite of the services they provided. Although the public did not know the academic qualification of non - professional nurses they were disregarded by the type and colour of uniform they wore. Lizzy recounted her experience as: “I was once assisting a doctor to do consultation in his office when a woman came in requesting the services of a private nurse. The doctor knowing my competence recommended me to the woman, but she said no! I am not a good nurse, so from that point on, the doctor asked me not to be wearing my uniform to the consulting room but rather mufti. All these instances are humiliating; it makes you feel bad and you are motivated to go back to school” Irene who is in school complained that: “The public even does not respect us, sometimes they address us as town council officials so by going back to school my uniform will change and people will now see that I am a qualified nurse” 4.3.9 Influence of Mentors and Role Models Role models played an influential role in participants returning to school for further studies. Participants acknowledged that role models made richer contributions to decision making and were highly admired by their works. Stella shared how she was motivated to pursue midwifery: 74 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “In terms of role models, I looked up to the midwives I worked with, I realised they were okay with life and did not have many problems. Their work was regarded and they were also respected, so I wanted to be like them” Cynthia acknowledged how the contributions from role models motivated her to go back to school: “When you attend programmes, you realize that individuals who have pursued continuing formal education made richer contributions and their knowledge is far richer than your so I also want to pursue continuing formal education so that I will stay on top of issues like my colleagues” While a number of participants were influenced by role models to continue their education, a number of participants furthered their education by their own initiatives. Naomi expressed her concerns as: “I did not have any role model who motivated me to pursue continuing formal education; I went to school by my own initiative” Participants who have completed school admitted they had become role models who are encouraging colleagues to further their education. Christabel who has completed school had this to say: Doris who has also completed school shared her experience as a role model: “My ability to pursue Bachelor of Science in Nursing has motivated other non - professional nurses to go back to school. Some are pursuing degree nursing. Now everyone talks to me, I have become a role model or a mentor; people are asking me how I did it” 4.4 Barriers to Continuing Formal education Education has become a necessity and the right of all individuals, but in one way or the other, there are barriers which tend to deter an individual from embarking on an educational programme. The barriers to continuing formal education encountered by participants are in three categories according to Cross (1981) chain of response model on adult participation in education. The first barrier identified emanated from the personal situation of participants the 75 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses moment they made up their minds to return to school. Barriers of this nature included marriage, pregnancy and participant’s inability to pay for tuition fees, hostel charges and transportation to school. Participants who have completed school and those enrolled in a programme of study encountered difficulties in getting money to pay for the services of care takers who cared for their children while they were away in school. [ The second barrier is problems with the educational institutions responsible for the education of non - professional nurses. Institutional barriers which prevented participants from continuing their education included lack of authentic information about educational programmes, inadequate advertisement on educational programmes, stringent institutional entry points which required participants to better their senior high school grades. Stringent entry requirement was a significant barrier for participants because they could not juggle work with remedial classes and family life. The third barrier focused on participants’ inability to cope with school and programmes as a result of previous experience with school. Generally, participants who have not continued their education encountered this barrier. While some participants were not interested in the available educational programmes, others felt content with life and were too old to learn. Others, on the other hand, could not stand the pressure surrounding the academic environment. Aside the first three barriers which are in line with Cross (1981) chain of response model, additional barriers that emerged from the data include barriers from employers of non - professional nurses and challenges arising from the management of healthcare facilities where nurses worked. 76 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.4 .1 Situational Barriers i. Family Responsibilities All the participants mentioned family responsibilities such as marriage, pregnancy and caring for children as a barrier preventing them from going back to school. Priscilla who is yet to enroll in a programme narrated her experience as: “Once I got married I assumed a different responsibility to my role as a nurse. And I think it’s going to be difficult combining these roles with school, but I am still thinking of favourable options to continue my education because I need to progress in life” Jennifer who is now in school shared how her decision to continue her education delayed as a result of pregnancy: “I realized all my colleagues were going to school, so I decided to go to school come what may, but unfortunately, the moment I bought the form, I realized I was pregnant but because of my zeal to go to school, I wanted to abort the pregnancy but my husband did not agree so I had to stay back and give birth” Victoria who has completed a continuing formal education programme shared her experience as: “Once you tell your husband about your decision to continue your education, he will ask, who will take care of the kids” Participants who have completed school and those currently in school complained of how thoughts about the welfare of their children distracted them when they were away in school. Cynthia who has completed school shared her story as: “Before I pursued the programme, I had already given birth to two girls and they were very young. Leaving them behind for school was a challenge to me. Although I left them with my mother, I always thought of them” Family responsibilities such as illness of children interfered with academic work. Participants have to abandon school to take care of sick children. For instance, Stella who was in school confirmed how her academics were affected: 77 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “At times you become so confused when you get a call from the house informing you that your child is sick. You are unable to concentrate on anything, you have to ask for permission and go home to take care of the sick child” ii. Financial Obligations Monetary challenges were a major barrier which deterred participants from going back to school. Challenges came in the form of caring for one’s family, cost of tuition, hostel fees, payment of care takers and cost of transportation to the educational institution. Susan who has not continued her education said that: “Financially, if your account is not fat, it is difficult going to school because you have your nuclear and extended family to take care of in addition to paying your school fees so always there is pressure on you” Irene who is in school had this to say: “Even if you get a helper to take care of your children, you have to pay for her services in addition to paying your school fees, accommodation and other expenses at school, so many a times you tend to delay your decision to go to school” Participants who are enrolled in a programme of study felt their school fee was expensive and they encountered challenges in paying. Stella who is in school confirmed that: “The school fees are too much, although some colleagues of mine got admission to enroll into a programme of study they could not pursue the programme because they had no money to pay for their fees” Lizzy who has completed school also asserted that: “Financial problem is a major challenge because you would have to buy handouts, if you don’t have money, you cannot survive. Going back to school requires adequate financial preparation” 4.4.2 Institutional Barriers Institutional barriers are found within educational institutions which deter non - professional nurses from enrolling in a programme of study. These barriers are lack of authentic information on educational programmes, improving senior high school grades and lack of counseling services in schools. 78 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses i. Lack of Authentic Information on Educational Programmes Participants complained of not getting valid information about existing educational programmes. Sheila who has not engaged in continuing formal education opined that: “The fact is we are not getting genuine information about the programmes, their entry requirements, fees and the duration involved” Victoria who has completed school narrated how difficult it was getting information about the programme she wanted to pursue: “My greatest barrier was difficulty in getting genuine information about the programme and it was really a bother to me because I had already applied and gotten admission, I was really disturbed when I was going to pursue the programme” Furthermore, participants who have not been to school complained that the information about educational programmes mostly came through social media and lacked credibility. Priscilla who has not engaged in continuing formal education declared that: “Through “WhatsApp” we get information about schools and programmes but as to whether or not it is true I do not know” While some participants acquired information about educational programmes through social media, others had their information through friends. Cynthia recounted how a friend assisted her in getting information about a programme: “I met a senior colleague who said there is a programme at Kintampo and that I could use my certificate to pursue without re - writing my senior high school exams” ii. Lack of Recognition for Educational Needs All the participants were of the view that educational planners responsible for their education did not consider their educational needs. Participants who have completed school wished they could advance in community health nursing but they were forced to divert to pursuing different programmes. For instance, Doris who has completed school maintained that: 79 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “Community health nurses love to advance in preventive nursing by pursuing either diploma in community health nursing or public health but this is not possible. I cannot pursue these programmes because of my basic certificate, but a general nurse who does not have any basic knowledge in preventive nursing can move straight to pursue public health…” Yvonne who has not engaged in continuing formal education stated that: “Educational planners know that it is going to be difficult combining work with remedial classes so why don’t they develop programmes we can pursue with our basic certificate” The majority of the participants also felt that, their efforts to advance in knowledge are not recognised when it comes to issues surrounding continuing formal education. Naomi who has completed school shares her opinions as: “Why are the authorities not encouraging us to pursue public health? We the nurse assistants who are not regarded are the ones who teach the public health students during their internships on the field, so why can’t they allow us to continue our education in preventive nursing. In fact, there is no respect for the non - professional nurses” iii. The Need to Improve Senior High School Grades Despite the fact that educational opportunities exist for non - professional nurses to continue their education at an advanced level, a greater number of them have to better their senior high school grades before being given the chance to enroll in these programmes. This has indeed become a great worry to participants. Cynthia who has completed school recounted how she was prevented from pursuing programmes she was interested in as a result of her basic certificate: “I was personally interested in nutrition and health promotion, but I was told I cannot apply with my certificate; I needed to better my senior high school grades” Rachael who was not successful in rewriting her WASSCE and so settled for a certificate in post basic midwifery narrated her ordeal as: 80 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “Rewriting the senior high school exam is difficult; myself I wrote it for two years I did not get better grades so I decided to go for the certificate in post basic midwifery programme” Conversely, participants who have not engaged in continuing formal education narrated how their inability to rewrite their senior high school exams delayed their decision to further their education. Yvonne who has not engaged in continuing formal education had this to say: “For me, I never tried rewriting the senior high school exams to go back to school, because I knew that even at high school if I could not pass, how much more now that am working. After working for three years, I decided to go back to school, but I did not like the certificate in post basic midwifery and this has really delayed my decision to go back to school” Participants complained that the fact that non - professional nurses were told to better their grades before pursuing advanced programmes would have an effect on midwifery practice. Non - professionals who could not rewrite the senior high school exam had no option than to settle for the certificate in post basic midwifery. Lizzy who was in school averred that: “A time will come that midwifery care in Ghana would be affected because most non - professional nurses are not interested in midwifery, but because they cannot better their senior high school grades, they are forced to pursue the certificate in post basic midwifery” Loretta who is currently enrolled in the certificate in post basic midwifery programme maintained that: “Somebody will go through midwifery and come out successfully, but after school, she might not love to do deliveries because she is not interested in midwifery. At work, she will always refer her cases and this is not the best as it retards our progress as a profession. I believe people should be given the opportunity to pursue courses of their choice” Some participants also lamented about how they had to divert to other disciplines because they could not better their grades. Christabel who has completed a programme of study expressed her emotions as: “If I had the opportunity to pursue diploma or degree in community, I would have loved to do so, but because my certificate could not take me there I had to pursue a different programme” 81 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses iv. Lack of Counselling Services in Schools Generally, participants complained of lack of interaction between representatives from schools and non - professional nurses on available educational programmes and how they could be assessed. Mercy who is in school asserted that: “My sister, in Ghana there is nothing like that, no one comes to talk to us about available educational programmes, and you would have to fish for the information yourself. Sometimes is really challenging and may deter us from engaging in continuing formal education” Additionally, participants who are in school complained of a lack of counselling services in schools. Doris who had completed school confirmed that: “At school, there is nothing like counselling services about the courses and programmes, the challenges we encounter at school and how to manage schooling with our family life” Cynthia who has also completed school emphasised the lack of counselling services in school as: “At times you feel the school is not concerned about your welfare. The school believes that you as an individual made the decision to come to school and so you should struggle to pass. I remember a school mate lost her baby but nothing was done to assist her in continuing her education” [ 4.4.3 Dispositional barriers Dispositional barriers evolved from the attitude, perceptions and feelings of participants about going back to school. The sub - theme, inability to cope with schooling experiences explain this theme. [ i. Inability to Cope With Schooling Experiences Although a greater number of participants were interested in continuing their education, they shared their opinion on why some non - professional nurses did not return to school. A major barrier which prevented them from continuing their education was the inability to cope with schooling experiences. While some non - professional nurses were not interested in the 82 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses available educational options; others were content with their lots in life and others also found it difficult to learn as a result of ageing. Others could also not stand the pressure surrounding the academic environment. Rose who is in school affirmed that: “The pressure at school is too much. Some colleagues of mine stopped school because they could not stand the pressure to learn. The old ones encounter learning difficulties; they sometimes sleep in class” Rachael also maintained that: “Majority of non - professional nurses are not interested in the post basic midwifery option so they are reluctant to continue their education” Lizzy also commented that: “Non - professional nurses are not going to school due to the fact that they would have to better their senior high school grades and this is difficult due to the new changes in the senior high school curriculum” 4.4.4 Barriers from Employer Participants in this study believed that barriers to furthering their education to a large extent emanated from their employer who is the government of the country. The sub - themes explaining this theme are a lack of academic progression opportunities and challenges with study leave. i. Lack of Academic Progression Opportunities All the participants argued that the government established schools to give them basic training in nursing without developing any educational progression opportunities for them. Eugene who has diverted to pursue a different programme maintained that: “The government is not concerned with our academic progression. As at 2003 when I completed community health nursing the only continuing formal education programme available at the time was the post basic midwifery. And being a male I would not be allowed to pursue midwifery, so I had to look for other educational options” Lizzy who has completed school also opined that: 83 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “I returned to school because the community health nursing I pursued was not a diploma. At my time there was no educational progression in community health nursing. So I diverted to pursue another programme. But believe you me, if there was a career progression such as from certificate in community health nursing to diploma in community health nursing I would have stayed” [ i. Challenges with Study Leave Challenges with study leave are a general concern for all non - professional nurses. Participants reported that getting study leave to continue their education was difficult even when they had served the required number of years to obtain study leave to pursue further studies. Sheila who has not continued her education had this to say “I have applied for study leave for about three times now but I have not been granted” Christabel who has completed school expressed her concerns as: “Getting study leave is an issue, if you don’t get study leave and you go to school you would not be upgraded. It is difficult getting it. Usually; it is given to those who have served longer years such as ten years above” A number of participants held the opinion that study leave issues are sometimes tied to district quota and choice of programmes chosen by heads of institutions. Eugene sustained that: “They should allow us to do courses of our choice. Sometimes, the directors would choose the courses for you, which is not fair, you realise this person is scared of blood, but she is being forced to pursue midwifery. A non - professional nurse might not be good in communication but he or she is forced to pursue health promotion. He will definitely fail in his courses” Participants in school complained that the one - year duration after which their intentions to continue their education was approved was too long. They explained that if a non - professional nurse was denied the approval to pursue further studies, it meant his or her decision to continue her education would be delayed. Doris who had completed school argued that: “The long procedure involved in the process of going to school is indeed a barrier. After working for five years, you have to declare your intention to go to school and this will take almost a year for processing. After a year, if 84 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses you are not fortunate you will be denied, meaning you have to wait for another year to declare your intentions to going to school again” In addition, participants were of the view that their heads of institutions made changes in the study leave policies regarding continuing formal education. Rose who is in school shared her concerns as: “Our chief directors make changes in the study leave policy. Some colleagues of mine got study leave to pursue distance programmes but their heads of institutions denied them the opportunity to go….., at times the heads would insist that, the nurses use their annual leave for the programme because they cannot be allowed to go for that long. Personally, I feel our authorities’ are infringing on our rights” 4.4.5 Challenges arising from Management of Health Care Facilities Participants complained that barriers hindering their decision to continue their education also originated from the management of health care facilities. Participants argued that irrespective of the fact that a non - professional nurse was due to continue her education; management of institutions sometimes delayed their decision to return to school. The sub - themes shortage of nurses and lack of organisational support explains this theme. i. Shortage of Nurses An inadequate number of nurses prevented management from allowing participants to continue their education. Rachael who is in school complained that: “Sometimes there would be only three qualified nurses in a district and they cannot allow all of us to go to school. When we all leave, there will be no one to do the work” Jennifer who is in school also declared that: “In some districts even after working for five years if there are fewer staff members you will not be allowed to go to school” 85 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses i. Lack of Organisational Support Participants complained of a lack of support from the organisations within which they worked as a barrier which made it difficult for them to return to school. Non - professional nurses in the study admitted that organisational encouragement to support nurses continue their education is on the low side. Some argued that their organisations were only interested in the work they did and are not concerned about how non - professional nurses would progress academically. Other participants, on the other hand, opined that they were intimidated when they made their decisions to return to school known to their authorities. Loretta who was in school corroborated that: “The system was not encouraging us to go back to school. The authorities would want us to work and work. Our decisions to return to school was not welcomed by our authorities” Sheila who has not returned to school expressed her concerns as: “Some of us are being intimidated by our superiors to abort our decision to go back to school. Some facilities will tell you that the course is not relevant to the facility. So you would not be allowed to go” In addition, the lack of encouragement to return to school also came in the form of distractions from hospital management. Stella who is currently in school explained her encounter with hospital management as: “My sister, going to school is not easy; before you make the decision to go to school, you have to go for an interview and even at the interview, you will be distracted, you will be asked a lot of questions which might discourage you from going to school. The reception at our places of work is not welcoming. The hospital management would not ask how beneficial the course will be to you, rather how it will benefit the hospital, so at times, you will not be given the study leave” Some participants also complained of degrading remarks from colleague workers as preventing them from going to school. Sheila has this to say: “Our elderly nurses are not encouraging us to go back to school rather they pass comments which deter us. I remember one elderly nurse, told me that, 86 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses why do you want to go to school, you have only one child, why don’t you give birth to another one and concentrate on taking care of them. Most elderly nurses have said this to me and it sort of makes me have mixed feelings about returning to school” The majority of participants who have not engaged in any form of continuing formal education also complained of a lack of support from co - workers as a barrier to their returning to school. Sheila who had not continued her education affirmed that: “I am not interested in the certificate midwifery programme; I want to pursue the diploma one, which requires that I attend remedial classes. I wanted weekends as my off duty days, but my in - charge said no, so I had to run night duties and this really affected me because most of the time I was late for classes” Faustina who is yet to continue her education also stated that: “Our superiors have become a hindrance to us. Sometimes our ward in - charges fight with us and they tell us bluntly that they will not allow us to go to school” 4.5 Measures to Enhance Continuing Formal Education of Non - professional nurses Measures suggested by participants to enhance continuing formal education of non - professional nurses are: 1) clear and effective governmental policies on education 2) educational programmes designed to meet the needs of students 3) collaboration between educational institutions and healthcare organisations on educational opportunities and programmes 4) Establishment of mentorship programmes 5) Organisational support for continuing formal education. 4.5.1 Clear and Effective Governmental Policies on Education All the participants were of the view that government should establish clear policies regarding continuing formal education. They opined that government should enforce laws that will make continuing formal education mandatory for non - professional nurses. Participants also wished 87 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses that the only continuing formal education programme which is the post basic midwifery should be upgraded to a diploma. Portia who has not returned to school stated that: “The post basic midwifery programme should be made diploma for non - professional nurses and parliament must enact a law for continuing formal education for non - profession nurses. Also, policies on study leave for non - professional nurses should insist on non - professional nurses meeting the minimum requirements. Rachael who has completed school also opined that: “Once we have a certificate, the government should upgrade the post basic midwifery to a diploma. After long years of working, I go back to school and I can only graduate with another certificate; it is very painful and this sort of decreases our enthusiasm to continue our education” Participants also maintained that once they are due for study leave, they should be given the opportunity to go to school; there should not be clauses such as “study leave will be approved for nurses who have served long years. Lizzy who is on a programme of study affirmed that: “Once the nurse has attained the number of years required for study leave, she should be allowed to go to school. They should not say someone has served for ten years and I have served for 5 years and so I should wait, this is not fair” Priscilla who has not returned to school wished that the government adhered to the study leave policies: “Government should stand by the study leave policy which states that non - professional nurses could pursue further studies after serving for five years and study leave should be granted to all nurses who qualifies” In addition, all the participants’ suggested that government should increase the number of times a non - professional nurse qualifies for study leave to continue her education. They argued that the two chances allotted for non - professional nurses to return to school under Ghana Health Service study leave policy were inadequate and that non - professional nurses need more opportunities to acquire higher qualifications. Rose who is in school expressed her concerns as: 88 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “They said we are entitled to only two study leaves under Ghana Health Service but this is not enough at least we should be given three chances” A number of participants who had not returned to school also complained of how changes in government affected their decision to pursue continuing formal education. They argued that a government may come out with a policy that we are training only midwives and so if the non - professional nurse is not interested in midwifery, then his or her study leave would not be approved. Susan who is not in school opined that: “The change in government also affects our schooling; no government should interfere with our educational policies. Every government comes with a new educational policy and this sometimes makes it difficult for us to return to school” Regarding issues with study leave, participants advocated that management of health care facilities should be educated on the study leave policies so that they do not make life uncomfortable for non - professional nurses who are due for study leave. Victoria who has completed school averred that: “Our in charges should be talked to so that they give us study leave to go to school because most of the time they become a hindrance to our going to school” Participants again declared that there should be a reduction in the number of years one has to serve to qualify for study leave. They wished they served for only three years as their professional counterparts did. Lizzy who was in school expressed her view as: “They should reduce the number of years that we have to spend on the ward before going back to school. At least 3 years is ok” Shallot who has not returned to school also emphasised that: “There should be a reduction in the number of years one has to serve to qualify for study leave because if am 29 years and I will qualify after 5 years of service, then I will be old and learning will be difficult for me” 89 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.5.2 Programmes Designed to Meet the Needs of Non - professional nurses Participants put forward that educational planners should consider the needs of non - professional nurses when continuing formal education programmes are being designed for them. Participants who have completed school and those currently in school wanted to pursue speciality programmes so as to meet the needs of the indigenous people within their communities. Doris who has completed school asserted that: “Majority of non - professional nurses are young; it’s only their senior high school results which have landed them as nurse assistants so they must be given the opportunity to do other post basics in different specialities like Eye, Ear, Nose and Throat so that they can practice within the communities. Once a non - professional nurse can treat an eye infection at the villages there is no need referring such cases to the hospital” Participants also stated categorically that if government could not grant study leave to all non - professional nurses who qualified to continue their education, then there should be an introduction of distance and weekend programmes so that they can work and learn concurrently. Eugene who has completed school suggested that: “I feel they should give us the opportunity to pursue weekend, evening courses and sandwich programmes with our leave after which they upgrade us” Yvonne who has not returned to school added that: “Distance courses and weekend courses are essential, so that non - professional nurses can combine work and schooling without asking for study leave” Majority of participants, who finds it difficult leaving their families behind especially young children to go to school, advocated that there should be introduction of programmes on the internet so that they could be with their families, work and still learn. Lizzy who have completed school maintained: “Our educational programmes should be designed on the internet so that we would not have to leave work for school. I work five days in a week so what happens to the two days; I can have classes on the Internet. Once there 90 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses are online courses, the non - professional nurse would not have to wait for five years to gain study leave before going to school. Learning should not always be in the classroom. Internet programmes are flexible and easy to access” Some participants suggested that their long years of service coupled with experience should be taken into consideration so that they could pursue diploma programmes without having to better their senior high school grades. Ruby who is in school opined that: “The government should allow us to use our senior high school results with the experience gathered on the field to further our education, because if we have passed the tertiary exam, why can’t we pass the diploma and degree programmes, why do we have to rewrite the WASSCE. They should consider the number of years on the field that we have served mother Ghana and our work output” Irene who is in school also stated: “The government should allow us to pursue the diploma programme with our certificate and working experience because some of us are old and learning has become difficult we cannot better our senior high school grades” A number of participants who had not engaged in continuing formal education were of the view that it was going to be difficult combining work with remedial classes to better their grades hence need for top up programmes to be organised for them to acquire certificates in diploma programmes. Priscilla who has not returned to school avowed that: “They should introduce weekends top up programmes in every region so that certificate nurses can take advantage of that to do the diploma and all nurses would be of the same standard and this will affect the care we give our clients. Teachers with basic certificates have been upgraded to diploma so why can’t the same be done for non- professional nurses” 4.5.3 Collaboration between Educational Institutions and Health Care Organisations on Educational Opportunities and Programmes Participants suggested that human resource managers should liaise with educational institutions to conduct periodic seminars on the educational mobility of non - professional nurses. They 91 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses declared that until non - professional nurses are educated on continuing formal education, they would be left behind in the nursing profession. Cynthia who has completed school maintained that: “Seminars should be organized in the various districts and regions by our human resource managers and educational institutions to educate non - professional nurses on their educational prospects. For me I think this should be made part of our orientation processes once we are recruited as health workers” Naomi who has completed school also emphasised that: “Representatives from the nursing training colleges should be visiting the district and educate nurses on how we can pursue continuing formal education and also point out which qualifications we need to further our education” All the participants also stressed on the fact that seminars and educational fora organized on continuing formal education should specify programmes which non - professional nurses can pursue with their basic certificate. They lamented on how lack of information have led majority of their colleagues to enroll in different programmes other than nursing. Kezia who has not gone back to school maintained that: “Education on continuing formal education should specify which programs are available for non - professional nurses and how they can be assessed. There are instances where some nurses have pursued some programmes which are not in line with the nursing profession and their certificates had not been recorgnised by Ghana Health Service e.g. a professional nurse had pursued public health, which is different from public health nursing and she is no longer working under Ghana Health service” Loretta who is in school advised that non - professional nurses should make the necessary enquires into educational programmes before enrolling unto them, she opined that: “Non - professional nurses before enrolling in a programme; should make enquiries and know what they are going in for. They should find out whether the school has been accredited and has the approval of Ghana Health Service and the Nurses and Midwifery Council of Ghana, because going back to school involves a lot of money and is painful when upon completion, one’s certificate is not recognised” 92 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 4.5.4 Establishment of Mentorship Programmes Participants suggested that there should be organization of mentorship programmes between non - professional nurses who have excelled in the nursing profession and upcoming ones to help bridge the barriers to continuing formal education. Christabel who has completed school stated that: “Registered nurses who were once non - professional nurses should help in the fight for non - professional nurses to continue their education but it looks like when they are able to progress in life, they forget about those of us left behind” Irene who is in school also emphasised that: “Nurses should ask about continuing formal education from role models and mentors and know how they were able to progress academically so that they follow suit” Some participants opted that mentorship programmes should be centred on the need for non - professional nurses to improve on their senior high school grades so as to pursue advanced programmes. Doris who has completed school opined that: “Every non - professional nurse can pursue a degree or diploma programme. Some should help themselves by rewriting the senior high school exams and should be prepared to learn, take risk and manage their monthly salary to assist in upgrading themselves in the profession” A number of participants emphasised that; upcoming non - professional nurses should upgrade themselves to higher levels before getting married. They opined that marriage comes with many distractions that will deter them from continuing their education. Eugene who has completed school stated that: “Male non - professional nurses are able to climb the academic ladder faster than our female counterparts, although the females are knowledgeable, marriage sometimes delay their abilities to continue their education” Participants also advocated that they would need expert education on financial management since they have to save money for their education. Rose who was in school maintained that: 93 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “The non - professional nurse who has not engaged in any educational programme should plan financially towards her education; she will need money for hostel fees, tuition, handouts as well as family expenses” A number of non - professional nurses who ever worked in remote villages advocated for strong communication between non - professional nurses in the urban and rural areas so as to motivate them to continue their education as some have become accustomed to the village life and would not like to progress in life. Lizzy who is in school stated that: “I believe non - professional nurses at the hinterlands needs to be assisted to return to school. At one promotional interview, I met a colleague I used to work with at the village, the moment she saw me in a white uniform she was impressed and said that no I have to leave the village to continue my education” 4.5.5 Organisational Support for Continuing Formal Education All the participants maintained that there should be organisational support to motivate non - professional nurses to continue their education. Yvonne who is yet to continue her education affirmed that: “Management of health care facilities should motivate us to go to school and also encourage us that after gaining four or five years working experience we should go back to school” The participants also maintained that management of institutions where they worked should support them to continue their education through reimbursement of tuition fees. Faustina who has not returned to school declared that: “Our school fees are very expensive and you have to pay with your salary, I believe that if our hospitals support us financially whiles in school, all non - professional nurses would be motivated to return to school” Participants suggested that hospitals should recruit more nurses to enable non - profession nurses to get the opportunity to further their education. Portia who has not been to school declared that: 94 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses “The government should train more young nurses to replace the older ones, so that once we leave for school; our absence will not be greatly felt and the work will go on successfully” 4.6 Summary of Findings The study focused on exploring the experiences of non - professional nurses on continuing formal education at the Pantang hospital in the Greater Accra region. The views of twenty - three participants were obtained using a semi structured interview guide and responses of participant analysed using the thematic content analysis approach. The study was guided by four objectives which were developed in line with the constructs of the Cross Chain of Response Model (1981) which focuses on the individual's decision whether or not to participate in an educational programme. The four main themes which guided the study were perception of continuing formal education, motivations for continuing formal education, barriers to continuing formal education and measures to enhance continuing formal education. The findings of the study showed that nurses perceived continuing formal education as important to their professional and personal lives. The participants held the view that by engaging in continuing formal education, they could acquire more knowledge and skills thereby upgrading their skills in the nursing profession. The study also revealed that several factors motivate nurses to return to school. The factors are both internal and external to the participants. While some nurses were self - determined to return to school others considered their youthful age and their desire to build on their professional competencies as factors motivating them to return to school. Lack of respect from colleagues and the health sector recognition for higher academic qualification for practice than one's experience in the profession also influenced some participants’ decision to return to school. The findings also showed that non - professional nurses do encounter a lot of barriers in their desire to continue their education. The barriers emanated from the personal situation of the nurse, the educational institutions responsible for the training of nurses, the organisations 95 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses within which nurses worked and the nurses own perception, feelings and attitudes toward continuing formal education. Regarding measures to promote continuing formal education of nurses, the study showed that nurses are eager for measures to be put in place to promote their continuing education. The nurses suggested that there should be clear and effective governmental policies on education, educational programmes should be designed to meet their needs, the need for collaboration between educational institutions and management of healthcare organisations as well as organisational support towards continuing formal education. 96 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses CHAPTER FIVE DISCUSSION OF FINDINGS 5.0 Introduction This chapter discusses the major findings of the study in connection with the related literature reviewed. The aim of the study was to explore the experiences of non - professional nurses on continuing formal education. The study delved into the perception, motivation, barriers and measures to continuing formal education of non - professional nurses. The four main themes that guided the study were: perception of continuing formal education, motivational factors for pursuing continuing formal education, barriers to continuing formal education and measures to enhance continuing formal education. The key findings identified from the study are as follows:  Non - professional nurses have a positive perception about continuing formal education. They consider continuing formal education as important to their profession as nurses and their personal development in life.  The motivation to pursue further studies originates from both internal and external factors to the non - professional nurse. Among these factors include self- determination, lack of respect from colleagues and the public.  The barriers to continuing formal education encountered by non - professional nurses sterm from the personal situation of the nurse, educational institutions, organisational factors and the non - professional nurse’s disposition towards education.  Measures recommended to enhance continuing formal education of non - professional nurses are: continuing formal education should be made mandatory by policy for non - professional nurses and measures should be put in place to develop continuing formal 97 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses educational programmes non - professional nurses could pursue with their basic certificate. These key findings identified from the study have been discussed under the four main themes that guided the study. 5.1 Perception of Continuing Formal Education An individual’s perception of a phenomenon may originate from his or her interaction with the environment or the world at large. In exploring the perception of non - professional nurses on continuing formal education, the findings from the study suggest that non - professional nurses have a positive perception about continuing formal education. Participants in the study argued that continuing formal education is necessary and important to their practice as nurses. These findings are similar to previous studies conducted to explore the perception of nurses on continuing formal education (Baxter et al., 2013; Govranos & Newton, 2014; Nsemo et al., 2013). All the studies looked into the perception of different categories of nurses, including nursing assistants and senior nurses; the nurses in these studies affirmed the importance of continuing formal education to nursing practice, especially non - professional nurses who are gradually building on their nursing portfolio. Thus no matter the academic qualification and designations of nurses in the profession, nurses may consider continuing formal education as paramount to their practice; hence the need for nurses to be motivated in the pursuance of continuing formal education. Non - professional nurses in the study perceived engaging in continuing formal education as a means of acquiring more knowledge and skills which would help them upgrade themselves in the profession. This finding is in line with that of Osterman et al. (2009) and Sarver et al .(2015) who found in their studies that nurses perceived continuing formal education as expanding their knowledge about the profession. Osterman et al. (2009) in their study found that older female 98 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses nurses aged between 40 and 50 years with about 14 to 34 years of working experience perceived engaging in continuing formal education as helping them to acquire more knowledge regardless of their age and working experience. Six years later, Sarver et al. (2015) also confirmed that female nurses with an average age of 43 years and about 15 years of clinical experience on the ward also returned to school because they wanted to acquire additional knowledge which would impact on their practice. This finding is significant as it depicts that no matter one’s experience and years of service in the nursing profession, acquiring additional knowledge is essential for nurses to practice within the standard. Thus, it is not surprising that this study found that in Ghana, younger non - professional nurses with an average age of 29 years and approximately 7years of working experience are also eager to return to school to acquire additional knowledge. [ Although the above studies found that, elderly nurses are eager to participate in continuing formal education in some countries, the reverse might be for elderly non - professional nurses in Ghana as shown by their lack of interest to participate in this study. The reason being that, study leave policy in Ghana does not favour elderly nurses return to school, elderly non - professional nurses after attaining the highest rank in the profession as a superintendent community health nurse or enrolled nurse with several years of working experience, receiving a higher remuneration and wears a white uniform which comes with recognition, might not be interested in returning to school to become a professional nurse which might require that she begins from the lowest rank of professional nursing as a staff midwife or nurse and serve for mandatory years to rise through the ranks of professional nursing. Hence, the majority of elderly non - professional nurses’ would rather prefer not returning to school at an advanced age. This may indicate the need for younger non - professional nurses who express interest in 99 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses returning to school to be supported in that direction so as to benefit from pursuing further studies at an early age. [ Another reason why participants’ desire to acquire additional knowledge is the fact that non - professional nurses’ consider their initial training as basic which becomes obsolete with time. This finding is in line with that of previous studies which indicated that the initial training received by nurses from their basic training would not sustain them throughout their entire professional life, hence the need for non - professional nurses to be given the opportunity to continue their education (Clark et al., 2015; Richards & Potgieter, 2010; Shahhosseini & Hamzehgardeshi, 2015). [[ Richards and Potgieter (2010) found that the acquisition of a higher qualification is a factor which pushes many nurses with senior level positions and has worked for about 21years to pursue continuing formal education. Similarly, this study found that non - professional nurses’ with the least rank in the nursing profession perceive engaging in continuing formal education as a means of acquiring a higher academic certificate which can be used in pursuing advanced programmes. This finding may suggest that nurses desire to acquire additional qualification to build on their practice. Furthermore, this finding is very important to the redesigning of nursing education for non - professional nurses in Ghana as the study revealed that a number of practicing non - professional nurses at the age of 37 years who have completed continuing formal educational programmes could only boast of their highest academic qualification as a certificate and this is likely to affect the growth of the nursing profession in Ghana. Thus more avenues should be created to promote the continuing formal education of non - professional nurses. 100 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Organisation of in - service training in the form of continuing professional development, conferences and workshops is essential as it aids nurses to bridge the gaps in their professional competencies and attitudes. The finding from this study indicates that, though participants get the opportunity to attend more conferences and workshops, non - professional nurses in the study suggested that they should be allowed to participate in continuing formal education as it presents them the chance to engage in intensive learning and offers them adequate time to learn unlike conferences and workshopswhich are limited and compressed in nature making it difficult for non - professional nurses to fully grasp what they are being taught. [ Similar to the above findings, Chong et al. (2014) found that, frequent organisation of continuing professional development programmes also makes it difficult for nurses to pursue further studies. This finding may suggest that in - service training though essential for updating nurses’ knowledge and skills on current happenings in the profession, continuing formal education is equally important for the professional development of non - professional nurses as Plunkett et al. (2010) also emphasised that continuing formal education impacts on nurses ability to engage in critical thinking and assume higher positions in the profession such as administrative and leadership positions. Thus stakeholders responsible for the education of non - professional nurses should promote the continuing formal education of non - professional nurses. Generally, nurses are charged with the responsibility of delivering quality health services to clients so that they have a shorter stay in the hospital and are discharged home without complications. This study found that non - professional nurses perceive engaging in continuing formal education as enhancing their clinical skills to better manage the health needs of their clients. Participants in the study declared that participating in continuing formal education will equip them with more knowledge and skills to better understand the health concerns of their 101 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses clients so as to offer quality health care to them. This finding corroborates that of other empirical studies which indicated that continuing formal education helps nurses to improve the quality of care offered to clients (Lerner et al. 2010; Nsemo et al., 2013; Richards & Potgieter, 2010). [ Lerner et al. (2010) in their quest to find out whether nurse assistants required additional knowledge to supplement their basic education maintained that nurse assistants are eager to advance their knowledge so as to improve their care giving skills. Similar studies in sub - Saharan Africa such as Nsemo et al. (2013) and Richards and Potgieter (2010) also confirmed that registered nurses perceive continuing formal education as assisting them in meeting the various needs of their clients thereby enhancing their satisfaction. Non - professional nurses perception that continuing formal education is essential in helping them improve their care giving skill is significant as all the empirical studies have duly acknowledged that, nurses no matter their level of education still craves for engaging in continuing formal education with the ultimate aim of offering better quality services to their clients. Measures are therefore needed to promote the continuing formal education of non - professional nurses. Continuing formal education according to participants has a profound impact on knowledge and practice as non - professional nurses asserted that by participating in continuing formal education they would be equipped with knowledge and skills which could be transferred to colleagues and students. This finding replicates that of Richards and Potgieter (2010) who opined that registered nurses irrespective of the difficulties they encountered in returning school, engaged in continuing formal education so as to successfully mentor others within the nursing profession. This finding is very important in our Ghanaian setting as majority of participants declared that, though they have not received professional training as nurses, they could perform some duties of the professional nurse, probably they also benefitted from 102 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses mentorship training. In addition, shortage of nurses has resulted in majority of non - professional nurses having to work in remote villages either alone or with the aid of an orderly, so by continuing their education, they could also mentor or train other colleagues who would assist them in the performance of their duties. [ Nursing as a profession is rapidly evolving with knowledge, skills and technology, consequently nurses try to stay abreast of these new developments by returning to school. This study found that non - professional nurses perceive continuing formal education as exposing them to current happenings in the nursing profession as well keeping their knowledge up to date. This finding complements the findings of Nsemo et al. (2013) and Perfetto (2015) who acknowledged that nurses perceive engaging in continuing formal education as helping them to be current with contemporary knowledge and skills in the nursing profession. However, Ni et al. (2014) identified nurses’ yearning to update their knowledge and stay acquainted with the newest happenings in the profession as a motivating factor which influences their return to school. This finding may suggest that, non - professional nurses are becoming aware of the insurgence of educated and enlightened clients who demands competence, quality services and accountability from their care givers hence the need to pursue further studies to stay updated. [ Returning to school is known to be linked to promotions in one’s rank. This study found that non - professional nurses perceive engaging in continuing formal education as bringing about promotions in their rank which is likely to be associated with an increase in salary. This findings replicates the findings of Pool et al. (2013) which confirmed that nurses perceive engaging in continuing formal education as bringing an increment in their salary. Interestingly, in Pool et al. (2013) study, participants confirmed that, continuing formal education programmes which trained nurses to return to bedside nursing did not necessarily bring about an enhancement in salary rather only continuing formal education programmes which focused 103 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses on other aspects of the nursing profession such as teaching and assuming leadership roles resulted in an increase in salary. However, non - professional nurses in this study perceived completing a continuing formal education programme as leading to promotion to a higher rank at the clinical side which is accompanied by an increase in salary. This variation in findings may be true regarding the differences in perception that may be held by non - professional nurses and professional nurses in their decision to pursue further studies as confirmed by Pool et.al (2016) who also found in their studies that nurses may hold different motives for engaging in continuing formal education as some would pursue further studies because they would like to deepen their knowledge about the profession, others on the other hand, return to school because they want to develop their career. [ In summary, the above findings from this study highlights the fact that an individual’s perceptions about continuing formal education largely have a profound influence on his or her decision either to participate in continuing formal education or not as depicted by the Cross (1981) chain of response model. The next section in the discussion centers on motivational factors which influences non - professional nurses to pursue continuing formal education programmes. 5.2 Motivation for Pursuing Continuing Formal Education The decision to participate in continuing formal education may require a conscientious effort on the part of the student. The study shows that non - professional nurses are motivated by several factors to return to school. Self-determination on the part of non - professional nurses was identified as a motivator which propels nurse’s decision to pursue further studies. Participants in spite of personal challenges, such as those arising from both the workplace and family struggled to enroll in continuing formal education. For instance, a number of participants narrated how in spite of their tight work schedules, they had to make extra time to 104 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses attend remedial classes to improve upon their senior high school grades to engage in continuing formal education. In addition, participants who were still in school found the academic environment to be challenging but persevered through these difficulties to complete their programmes of study. Similarly, Richards and Potgieter (2010) found that nurses did encounter a lot of difficulties in returning to school as some registered nurses could not catch up with their class schedules and so wanted to abandon their programmes of study without completing. Perfetto (2015) on the other hand confirmed that, dedication and commitment was a motivating factor which enabled majority of nurses to stay on their programmes of study. These findings may suggest that, irrespective of the challenges non - professional nurses encounter in their desire to further their education, majority of them are personally motivated to return to school. [ Youthful age is assumed to be associated with vigour, strength and power, where an individual can really explore and concentrate on what he or she is being taught at school without much distraction. Thus, this study found that non - professional nurses are motivated to return to school because they are young. Participants believe they possess the potentials to do more for themselves and the nursing profession. This finding is in line with the findings of Alamri et al. (2015) who found that majority of nurses aged between 26 to 29 years with at least 6 years working experience were highly motivated to return to school. The prime motive why nurses in Alamri et al. (2015) study returned to school was to acquire additional credentials, likewise non - professionals nurses in this study pursued continuing formal education because they wanted to attain greater heights within the profession and do not want to forever remain as nursing assistants. This finding is important as it supports the claim by psychologist that, it is easier to learn when one is younger than when he or she has advanced in age. The finding may also suggest that more attention should be geared towards promoting the continuing formal education of non - 105 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses professional nurses at an early age so that they would not be disadvantaged but rather benefit abundantly from their efforts in terms of the opportunities that come with schooling. Secondly, when younger non - professional nurses are assisted to pursue continuing formal education at an early age, they can contribute more to upholding the image of the nursing profession than the ageing population of nurses’ who would soon retire from active service. Richards and Potgieter (2010) asserted that registered nurses returned to school, based on their desire to build on previous knowledge. This study also revealed that non - professional nurses are motivated to return to school as a result of their low academic qualification which some participants admitted they were ashamed off and made it difficult for them to be employed by private healthcare facilities. Other participants also confirmed that their low academic qualification required that they were supervised to carry out some procedures on the ward even though they could perform it better. Similarly, Hutchinson et al. (2011) in their quest to explore the experiences of enrolled nurses in a Bachelor of Science in Nursing programme maintained that, despite the fact that the enrolled nurses had returned to school to pursue advanced programmes, they were aggrieved when they were only allowed to participate in basic procedures during their clinical sections even though they had the experience and skills to perform such procedures. This finding may indicate that non - professional nurses acknowledge the fact that, their basic knowledge about the profession has become an obstacle to their delivering of quality care to their client’s, therefore the need for them to be supported to pursue additional studies. In addition, the study confirmed that non - professional nurses are motivated to return to school because they want to progress in life. Participants declared they were not comfortable with their designations in the profession as nursing assistants because it delayed their progression in life. Particularly, nurses who worked in rural areas felt the village life was not conducive to their 106 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses personal development in life; many had delayed marriages and broken homes, thus wanted to go back to school to explore other opportunities in life. This finding builds on the findings of Nsemo et al. (2013), Pool et al. (2013) and Witt (2011) that confirmed that registered nurses were motivated to engage in continuing formal education as a result of their own personal interest, their desire to enhance their personal development in life and the chance to unravel several opportunities such as networking and new career options. Deducing from Witt's (2011) study, several opportunities await non - professional nurses when they are able to successfully complete their continuing formal educational programmes. This may require that measures are put in place to promote the continuing formal education of non - professional nurses to help them make meaningful contributions to the profession. As without their return to school, the farthest non - professional nurses can go in the profession is to become either a superintendent enrolled nurse or community health nurse and remain as auxiliaries without the opportunity to become a professional nurse. [[[ The study again found that non - professional nurses are motivated to return to school because their employers do not appreciate their long years of working experience without acquiring a higher qualification. Some participants maintained that, after long years of serving their employer and accumulating much experience, a novice in the profession who has a higher qualification automatically becomes their boss even though he or she may not have much working experience. Similarly, Nsemo et al. (2013) found that nurses are likely to pursue continuing formal education if it would build on their professional status. Ni et al. (2014) opined that nurses’ return to school with the urge to acquire a higher certificate that would help them preserve their professional status. These findings may suggest that non - professional nurses admit their lower academic qualification as an obstacle to their development within the 107 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses nursing profession and this hinder their opportunity to offer the best of care to their clients, hence the need to pursue continuing formal education. The study further showed that lack of professional competencies on the part of non - professional nurses is a motivating factor which encouraged their decision to return to school. Participants in the study disclosed that, in as much as they were efficient with the practical aspect of nursing, their theoretical know - how was deficient. Participants further added that once they become proficient in the profession, they are likely to work without any supervision. This finding replicates the findings of other studies which indicated that nurses returned to school because they want to build on their proficiency and learn new things which will help them in their practice (Ni et al., 2014; Shahhosseini & Hamzehgardeshi, 2015). This finding emphasises why continuing formal education is essential for non - professional nurses as nurses want to be capable of meeting the diverse needs of their clients and are no longer satisfied practising with intuition or trial and error. This necessitates the need for evidence based practice to be inculcated in the nursing curriculum so that nurses would really understand the rationale behind their practice. [ The study also found that non - professional nurses are motivated to return to school as a result of their drive for other career options. A number of participants lamented that their work was laborious and leaves them little time for leisure and relaxation. Other participants wanted to change their jobs because they could not stand the harsh treatments they received at work. Thus, they hoped that by continuing their education formally they will get better career options which are less stressful and better met their needs. These findings align with the findings of Perfetto (2015) and Richards and Potgieter (2010) which indicated that nurses were motivated to return to school because they found their nursing work to be difficult; consequently their desire for different career options. This finding is important as it points out that nurses consider 108 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses their jobs to be stressful. Measures should, therefore, be instituted to make nursing work less stressful, so as to encourage more nurses to stay on the job. The researcher may suggest that the training and recruitment of additional nurses to assist those who are currently on the field, as well as the provision of flexible work schedules and incentives, would at least reduce the burden of nurses’ and make nursing as a profession more appealing to the upcoming generation. [[ Job description spells out the functions and responsibility of every worker who is employed to offer services to consumers. In the same way, non - professional nurses after being employed are given a detailed description of what their job entails and what is expected of them as nurse assistants but this study confirmed that majority of non - professional nurses returned to school because they found themselves working outside their job description. The situation at their work places compels them to perform the activities of professional nurses such as conducting deliveries and passing nasogastric tubes to feed patients. In Ghana, non - professional nurses working outside their job description is widespread. For instance, many community health nurses who work in remote villages have basic training in conducting deliveries, but these non - professional nurses feel insecure with their work because they are practising without any midwifery license as this can bring about medico - legal issues. As a result, majority of participants are eager to continue their education to be trained as professional midwives in order to practise with the right academic qualification. The study further found that majority of the participants’ are motivated to return to school because of lack of respect. This lack of respect is in part from colleagues and the general public. While some participants lamented they were treated as inferior beings at their work places and their work as nursing assistants were not appreciated, other participants were also discriminated by the public as unqualified nurses. Participants who were able to enrol in continuing formal education programmes complained that even at school they were disrespected by school mates 109 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses and were considered as non - knowledgeable nurses and these have become self – esteem issues for the participant. Similarly, nurses in Pool et al. (2013) studies, acknowledged that they could enhance their self - esteem by pursuing continuing formal education programmes that would earn them higher qualifications. Other nurses wanted to pursue programmes that would not bring them back to bedside nursing as they felt practising at the bedside reduced their self - respect. [[ This finding is relevant and requires urgent attention, because decreased self - respect on the part of the non - professional nurse can affect the nurse assistant herself, the patients under her care and the organisation within which he or she works. The researcher may suggest the need for counselling services to be provided at the workplaces of nurses to explore factors that contribute to the development of low self - respect among nurses and immediate interventions implemented to resolve them. [ Another factor which motivates non - professional nurses to engage in continuing formal education is the influence of role models and mentors. Participants in the study opined that the contributions made by mentors at their workplaces were motivating factors for returning to school. Other participants also stated that their ability to complete the Bachelor of Science in nursing programmes has made them role models who are also encouraging other colleagues to continue their education. This finding complements that of Richards and Potgieter (2010) and Skela - Savič and Kiger (2015) who indicated that role models and mentors had a part to play in nurses return to school for further studies. Although Richards and Potgieter (2010) found that registered nurses participated in continuing formal education because they were motivated by role models and mentors, Skela - Savič and Kiger (2015) emphasized the need for more professional training for clinical nurse mentors and role models in continuing formal education, research and learning programmes so that they can be more influential to nurses as well as 110 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses students. Similarly, in Ghana, more mentors and role models in the nursing profession are required to boost the morale of the younger generation of nurses to continue their education and attain greater heights so as to make meaningful contributions to the practice of nursing. 5.3 Barriers to Continuing Formal Education Identifying the barriers to continuing formal education is essential as this will help in devising strategies to counteract the barriers that make it challenging for non - professional nurses to engage in continuing formal education. Responsibilities associated with caring for one’s family are identified as barriers which prevented the majority of participants from engaging in continuing formal education. As some participants could not combine family life and work with schooling. Pregnancy also deterred others from pursuing further studies. Participants who had successfully enrolled in a programme of study complained of how family problems and illnesses of their children made it difficult for them to concentrate on their studies. These findings harmonise that of Schweitzer and Krassa (2010), Rouse and Rooda (2010) as well as Hutchinson et al. (2011) which indicated that family responsibilities were a deterrent to nurses participation in continuing formal education. According to Hutchinson et al. (2011) attending to family responsibilities prevented nurses who were enrolled in a programme of study from engaging in socialisation processes on campus as they felt they needed more time for their studies. Rouse and Rooda (2010) further maintained that majority of nurses in their study were unable to complete their programme of study as a result of the illness of family members and having to take on extra jobs to meet the needs of their families. Similarly, non - professional nurses in Ghana; desire to continue their education but family responsibilities have become a major barrier for them. This finding may require that the non - professional nurse while receiving their basic training in school are sensitised by faculty on the need to plan towards pursuing 111 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses continuing formal education upon completion. Additionally, there could be the introduction of online programmes which would make schooling easier for non - professional nurses with family responsibilities to juggle schooling with caring for their families. Monetary challenge is also another barrier which dissuades non - professional nurses from pursuing further studies. Participants admitted that going back to school is an expensive project which requires that you pay for high tuition fees, hostel fees in addition to other expenses made in school. Another challenge encountered by non - professional nurses who have returned to school is the need to pay for the services of care takers who took care of their children while they are in school. Duffy et al. (2014) also identified that financial difficulties were a barrier which deterred nurses from pursuing continuing formal education. The authors further suggested that, in addressing the issue of financial problems encountered by nurses in returning to school, the organisations within which nurse’s work should be willing to assist nurses pay their fees in the form of tuition reimbursement. moreover, organisations within which non - professional nurses work should organise educational forums which will educate nurses on prudent ways of saving money towards continuing formal education (Rouse & Rooda, 2010). Another barrier which deterred nurses from pursuing further studies is the difficulty in getting authentic information about available educational programmes. The study showed that participants who chanced on information on educational programmes got them through social media and friends. This made it difficult to judge the genuineness of the information and really delayed their decision in participating in continuing formal education as a number of participants could not ascertain the prospects of the available educational programmes. Similarly, Richards and Potgieter (2010) found that difficulties in obtaining information about educational programmes was a barrier which deterred non - professional nurses from pursuing further studies. Non - professional nurses in this study resorted to social media and friends to 112 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses acquire information about educational programme, probably because majority of them worked in remote villages and cannot get access to the internet. This might not be the best way of acquiring authentic information about educational programmes. The researcher may suggest that obtaining reliable information about schools and programmes may require that non - professional nurses either visit the website of these educational institutions or make personal visits to the schools to make such inquiries. [ Lack of recognition for the educational needs of non - professional nurses also came up as a barrier which prevents the majority of participants from pursuing continuing formal education. Participants lamented that they are not interested in the available educational options as it did not meet their needs as learners. In as much as non - professional nurses who received their initial training as community health nurses, desired to continue their education in preventive nursing by pursuing either diploma in community health nursing or public health nursing, their basic certificate could not assist them in enrolling in such programmes. This challenge is the same for non - professional nurses who were trained as enrolled nurses and desire to pursue straight diploma programmes but are denied access because they cannot enroll in such programmes with their nursing assistant certificate. This finding complements the findings of Nalle et al. (2010) and Perfetto (2015). [ According to Nalle et al. (2010) nurses are likely to engage in continuing formal education, if the programmes met their needs as learners. Perfetto (2015) also maintained that nurses are ready to pursue continuing formal education if their basic training and experiences will be accepted by the educational institutions. In Ghana, the initial training of non - professional nurses is not considered as adequate to help them enrol in advanced programmes. This finding may suggest that educational programmes should be designed to meet the needs of non - professional nurses which will motivate these nurses to engage in continuing formal education. 113 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Another implication of this finding is that, in the Ghanaian setting, non - professional nurses’ lack of interest in the available educational programmes may pose a serious challenge to the profession as some nurses can practice for so many years without upgrading their knowledge. From the researcher’s experience from clinical nursing in the past eight years, it is evident that non - professional nurses who do not show any interest in pursuing continuing formal education are likely to have a reduced interest in attending in - service training programmes. Thus, they stick to their old ways of practicing nursing and obviously the innocent patient becomes their victim and could be denied of appropriate nursing care. [ Although, continuing formal education programmes exist for non - professional nurses to enroll in, the study identified that participants’ need to better their senior high school grades before they could be admitted to pursue such programmes. This becomes a great challenge to non - professional nurses as they cannot juggle work, family life and attending remedial classes to improve their senior high school grades. For instance, a number of participants declared how unsuccessful they were after several attempts to better their grades, as a result, they settled for the certificate post basic midwifery which upon completion they will earn another basic certificate which cannot be used in pursuing advanced programmes. Other participants who were not interested in certificate post basic midwifery either do not continue their education or divert to different disciplines such as community psychiatry, nutrition or health promotion. Similarly, Nsemo et al. (2013) found that nurses are not likely to pursue further studies if the academic qualification obtained upon completion of a programme cannot be used in pursuing advanced programmes. [ This issue of non - professional nurses enrolling in certificate post basic midwifery could be a threat to midwifery care in Ghana. The majority of participants argued that there would be a time in Ghana, when would have dispirited and demoralised midwives who would not enhance 114 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses midwifery practice. This is because a number of non - professional nurses are forced to pursue the midwifery programme because they cannot better their grades to pursue other advanced programmes of interest. The researcher suggest that, it is time the needs of non - professional nurses’ regarding continuing formal education and their future career options are assessed and measures put in place to meet their learning needs. Otherwise Ghana as a country will continue to record increased incidences of both maternal and infant mortality even though the country might be training adequate number of midwives to meet the midwifery needs of the country. [ Lack of counselling services in schools is another barrier which participants declared made it difficult for them to complete their programmes of studies. The study revealed that, though participants wished to have an initial interaction with schools to be briefed on the available educational programmes, their prospects and how they could be assessed; the study showed that there is nothing of that sort. Participants after enrolling in continuing formal educational programmes commented on how they encountered difficulties in adjusting to the challenging academic environment as they did not know who and where to turn to for help. This finding builds on the findings of Hutchinson et al. (2011) who also found that, enrolled nurses in their study did encounter a lot of difficulties while in school and had challenges in getting accurate information about their programmes as well as how to deal with their expectations at school. Burton et al. (2011) also emphasised that the initial association of educational institutions with potential students before they enrolled in their programmes of study helps in lessening the academic burden of students. This finding may highlight the need for counselling services to be provided in schools as adult education is associated with challenges which make learning difficult. The adult learner might have no option than to decline his or her decision to continue their education. [ 115 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Another barrier which emanated from the study is a dispositional barrier which centers on non - professional nurses’ feelings, attitudes and expectations about school, which makes it difficult for non - professional nurses to cope with school because they are less interested in returning to school. This finding indicates that, while some non - professional nurses are not ready to return to school because they cannot stand the pressure surrounding the academic environment, others simply do not have the time to learn and are not interested in the available educational options. Others are also not prepared to better their senior high school grades. Participants also maintained that elderly non - professional nurses are not likely to return to school because they feel they would be disadvantaged upon completion as they have to start again at a lower rank in professional nursing. [ Similar to the above findings, Richards and Potgieter (2010) maintained that registered nurses did not enroll in continuing formal education because they were ill prepared and did not have the strength to return to school, whereas other nurses did not perceive the relevance of the existing educational programme. Muliira et al. (2012) also found that one’s experience on the field and old age prevented the majority of nurses in Uganda from pursuing further studies as some held the perception that caring for a patient does not demand embarking on continuing formal education. This finding requires that measures are put in place to stimulate the interest of non - professional nurses into returning to school because the nursing profession is dynamic and advancing rapidly with technology and research. Hence nurses are required to move along in order to uplift the image of the profession. Another barrier identified which makes it difficult for non - professional nurses to return to school has to do with the employer; the government of the country. A number of participants argued that, though the government established programmes to assist in their initial training as nursing assistants, no arrangements have been made towards their academic progression after 116 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses their basic qualification. Similarly, Ikenwilo and Skåtun (2014) identified that unavailability and an inadequate number of continuing formal education programmes prevented doctors from engaging in continuing formal education. Nsemo et al. (2013) also maintained that nurses were motivated to enrol in continuing formal education because it has been made mandatory by their state. In Ghana, the situation is different, as programmes that non - professional nurses can pursue directly with their basic certificates are not available. Nurses who cannot better their grades to pursue the existing educational programmes are left with no option than to work for so many years without pursuing continuing formal education which obviously affects their performance as nurses and healthcare providers. [ The study furthermore, identified challenges with getting study leave as another barrier which made it difficult for non - professional nurses to enrol in continuing formal education. A number of participants admitted that it is very challenging getting study leave as some had applied for three consecutive times without being successful. This finding builds on that of Coventry et al. (2015) who acknowledged the challenges confronted by nurses in obtaining either paid or unpaid study leave made it difficult for nurses to return to school. The study revealed that some heads of healthcare facilities only approved study leave for non- professional nurses who are ready to pursue programmes that the district have identified as important to the health needs of their clients and not what the non - professional nurse is personally interested in. Similarly, Munro (2008) also found that the differences in organisational educational demands and the individual nurse’s preference towards continuing formal educational programmes make it difficult for nurses to return to school. This finding is significant, as in the Ghanaian context nurses can only pursue continuing formal education when they have the approval of their employer by acquiring study leave with or without pay for a stipulated number of years. This means that without study leave, the non - 117 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses professional nurse cannot leave for school and even if they did pursue further studies without approval, their certificates would not be recognised by their employer upon completion. This finding may require that measures are put in place to expedite the process of acquiring study leave so that all non - professional nurses would be motivated to continue their education formally. This finding may also call for the introduction of more online, weekend and sandwich programmes for nurses to help the majority of non - professional nurses to return to school to pursue programmes of their choice without having to wait for so many years to be given the permission to return to school. [ The study found that another barrier which dissuades nurses’ decision to return to school is a shortage of nurses in their workplaces. Some participants argued that although they qualify for study leave to return to school, they were not given the permission because when they leave for school; there will be no nurses to work. This finding harmonises the findings of Coventry et al. (2015) who identified that nurses were not returning to school because of a shortage of nurses at their places of work. Though, this finding necessitates the training of more qualified nurses to support the clinical work, the government of Ghana who is the employer of non - professional nurses should do well in recruiting the already trained qualified nurses who have been denied employment for the past two years after completing their programmes of study. The study also identified lack of organisational support towards learning as a barrier which hinders non - professional nurses’ decision to return to school. A number of participants felt their intention to return to school was not welcomed by their hospital management. According to participants, non - professional nurses are only regarded as employees who have been paid to work and do not have the right to return to school. Other participants also complained of how in - charges and colleagues at work make it difficult for them to return to school. Especially, participants declared that their in - charges do not prepare the duty roster to suit 118 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses their decision to attend remedial classes to better their senior high school grades to pursue advanced programmes. This finding is in line with that of other studies which confirmed that lack of organisational support makes it difficult for nurses to return to school (Netsanet Fentahun & Molla, 2012; I. Pool et al., 2013; Richards & Potgieter, 2010; Shahhosseini & Hamzehgardeshi, 2015). [ Richards and Potgieter (2010) argued that organisational environment which does not support learning makes it difficult for nurses to further their education. Fentahun and Molla (2012) also added that lack of support from employers was a barrier which hindered health care professionals working in a public health facility in Southwest Ethiopia from pursuing continuing formal education. Shahhosseini and Hamzehgardeshi (2015) also indicated in their study that, younger nurses did not engage in continuing formal education, because the duty roster at their workplaces was not designed to favour their participation in continuing formal education. Pool et al. (2013) further added that although ward managers in their study were not a hindrance to nurses furthering their education, their study identified that, nurse managers preferred to work with younger nurses who were ready to work at the bedside without engaging in continuing formal education. The nurse managers held the perception that nurses who had an interest in pursuing further studies seldom stayed on the ward and rather ventured into different sections of the profession such as leadership, research and academia. [[This finding is important because in Ghana ward in - chargers and heads of healthcare facilities play a very important role in whether the non - professional nurse would be granted study leave to pursue further studies or not. The process of acquiring study leave begins with recommendations from ward managers to management. Management then, upon further deliberations decides whether the nurse’s request should be granted or not. The situation however, is different as majority of participants declared that their management especially ward 119 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses in - charges makes it difficult for them to return to school, this may imply that for nursing education to be upheld in Ghana, there may be the need for heads of institutions within which nurses work to be sensitized on the importance of continuing formal education so that they assist in promoting the continuing formal education of non - professional nurses. Nevertheless, this must be regulated as nurses are needed to work at all times and the system can also be abused as seen in Ghana currently that many nurses are going to school without permission and most of the wards are empty even though their names are on the pay roll. 5.4 Measures to Enhance Continuing Formal Education Regarding measures to promote the continuing formal education of non - professional nurses, the study found that non - professional nurses want the government who is their employer to establish clear and effective policies regarding their continuing formal education. A number of participants wished a policy is enacted to make continuing formal education mandatory for all non - professional nurses. Some participants wished that the only available continuing formal educational programme (Certificate post basic midwifery) which they can pursue with their basic certificate be upgraded to a higher qualification such as diploma and degree in midwifery. Furthermore, participants wished that all non - professional nurses who qualify for study leave are granted the chance to pursue further studies without much hesitation. Similarly, Rodrigo et al. (2017) found that the government played an important role in upgrading nursing education to university education so as to train a highly competent nursing workforce who would meet the health needs of the people of Spain. Gao et al. (2011) also found that promoting nursing education in the Peoples Republic of China required that, basic secondary education which was designed to train young girls in the nursing profession needed to be upgraded to a higher level so as to enhance their practice as professionals. This finding may suggest that governments have a part to play in promoting 120 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses nursing education since nurses form the majority of the healthcare workforce in every country. This finding may also suggest that once government makes the provision for continuing formal education programmes, the non-professional nurse will now decide whether or not to return for further studies and this compliments the Cross (1981) chain of response model which affirms that the decision to participate in adult education single handily rest on the individual. [[[ The study also found that in order for the continuing formal education of non - professional nurses to be enhanced, non - professional nurses in the study want their needs as learners to be considered by educational planners when designing continuing formal education programmes. The study revealed that non - professional nurses want to be given the opportunity to pursue speciality programmes like ophthalmic nursing, Ear, Nose and Throat nursing etc. Other participants expressed interest in pursuing weekend, distance and online programmes which would offer them much time to be with their families, work and at the same time learn. Participants argued that introduction of weekends and distance course would mean that they would not have to wait for so many years to obtain study leave as they could use their annual leave and weekends in pursuing continuing formal educational. Similar to the findings of this study, Nalle et al. (2010) also found that, in enhancing nurses engagement in continuing formal education, it is important for nurses’ needs as learners to be assessed and measures designed to meet those needs. Pool et al. (2013) also emphasised the need for educational planners to take into consideration the different motives for which nurses would return to school such as broadening their knowledge base or developing a career. Ross et al. (2013) further added that addressing the needs of nurses in designing continuing formal education programmes require that, their different learning styles are taking into consideration. [ 121 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Regarding participants desire to pursue speciality programmes, Chong et al. (2014) found that in Malaysia, registered nurses returned to school because they wanted to pursue speciality programmes in cardiopulmonary resuscitation and wound management. Karaman (2011) and Cathro (2011) also emphasised how online education offered nurses much time to engage in continuing formal education irrespective of their personal responsibilities, work schedules and the fear of returning to school. Supporting the fact that introduction of online programmes make schooling easier for nurses, Lahti et al. (2014) and Gould et al. (2014) cautioned that online education has its own challenge. Hence measures should be put in place to address the challenges that are associated with its usage. Another suggested measure by participants to promote continuing formal education of non - professional nurses is the collaboration between healthcare facilities and educational institutions in promoting continuing formal education for non - professional nurses. A number of participants recommended that human resource managers of healthcare facilities where non - professional nurses’ work should liaise with educational institutions to conduct periodic educational fora on available educational opportunities, their prospects and how they can be assessed as part of the induction of new staff in all healthcare facilities. These findings builds on the findings of Brekelmans et al. (2013) who maintained that nursing experts in Delphi also advocate that; for continuing formal education of nurses to be enhanced, there is the need for collaboration between all stakeholders responsible for the education of nurses. Fitzgerald et al. (2014) also confirmed that collaboration between all stakeholders responsible for the education of nurses is essential for the promotion of continuing formal education. The authors found that nurse assistants in Ontario were able to successfully enrolled in a programme of study and complete as a result of the partnership between the heads of their educational institutions and the healthcare facilities where they worked. Rouse and Rooda (2010) further 122 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses added that early acquaintances of educational institutions with non - professional nurses should not only be done for prospective students, rather nurses who have successfully enrolled in an educational programme should also be orientated on their programmes of study as well as the academic expectations required of them. This finding is significant as it calls for the support of all stakeholders responsible for the education of nurses to promote the continuing formal education of non - professional nurses. This finding may also imply that the decision to return to school does not solely rely on the adult as stated by Cross (1981) Chain of Response Model, which highlight the fact that the adult learners perception on education, his or her attitude towards education, expectations for participation, information regarding the educational programme and barriers which may hinder his or her decision are the only factors which influences his or her decision to enroll in an educational programme. [[[ The study found that another measure to promote the continuing formal education of non - professional nurses is the need for mentorship programmes to be organized between non - professional nurses who have excelled to greater heights within the profession and upcoming non - professional nurses. This is to assist non - professional nurses to continue their education to become professional nurses. A number of participants suggested there should be mentorship programmes on how to improve senior high school grades and financial management so that they can save enough money towards returning to school. This finding is in line with the findings of Skela - Savič and Kiger (2015) who found that nurses needs to be mentored by clinical nurses who engages in educational and research programmes as well as developing their career path. Rouse and Rooda (2010) also maintained that for students to enroll and successfully complete their programmes of study there is the need for nursing faculty in the various educational institutions to take upon themselves to mentor these students by supporting them academically. 123 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses [In addition to Rouse and Rooda (2010) earlier submission, the authors argued that there is the need for student nurses to be educated on how to draw personal budget to save money and also seek financial assistance to support their education. These findings are very important in the Ghanaian context as we have few nursing mentors who are ready to assist others excel in the profession. This calls for more nurses; be it professional or non - professional nurses to continue their education formally to serve as role models as well as mentor others. [[[The final measure identified to promote the continuing formal education of non - professional nurses is the need for healthcare facilities within which non - professional nurses’ work to support their decision to continue their education. Some participants maintained that they need organisational encouragement to return to school and that their facilities should recruit more nurses to curb the shortage of nurses which deters their plans of returning to school. Others also want their healthcare facilities to assist them in the payment of their school fees and be respected and cherished by their facilities. This finding is consistent with that of Coventry et al. (2015), Shahhosseini and Hamzehgardeshi (2015) and Govranos and Newton (2014) who pointed out that leadership of institutions such as nursing managers should take the lead in creating an organisational culture which promotes continuing formal education and lifelong learning of nurses. [[ Munro (2008) also emphasized that, the creation of an organisational culture which supports learning requires that both the educational needs of the organisation and that of the nurse are met. Additionally, Richards and Potgieter (2010) maintained that organisational culture that supports learning requires that management of healthcare facilities work out staff development plans for their nurses and communicate such plans with them. The authors further added that nurses who form the greatest part of the healthcare system should be valued and respected by their organisations. Their study also encouraged nurses to take their performance appraisals 124 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses seriously so that their employers would know their educational needs and assist in meeting them. This finding is significant, because in the Ghanaian context although nurses are granted study leave to pursue further studies, the organisational culture of promoting continuing formal education among nurses is low. This calls for sensitization of all hospital management including medical superintendents, administrators, human resource managers and nursing administrators on the importance of supporting nurses to return to school for further studies as the individual nurse does not only benefit from returning to school but rather the effect triples down to the patient and the healthcare facility as a whole. 5.5 Summary of Discussion In summary, the study found that non - professional nurses have a positive perception about continuing formal education as they believe it will promote both their professional and personal development in life. Non - professional nurses are motivated to return to school because they consider themselves youthful, have plans of progressing in life such as acquiring a higher academic qualification, have better career options and redeem their image in the profession as they are least respected by their colleagues workers. [ The study found that the barriers which make it challenging for non - professional nurses to return to school includes situational barriers which are in the form of family responsibilities and financial obligations. Some barriers also emanated from educational institutions responsible for the training of nurses and they include difficulties in getting authentic information about programmes, lack of recognition for the educational needs of non - professional nurses and the need to improve upon senior high school grades. The third barrier identified is a dispositional barrier which focuses on the non - professional nurses’ attitude, perceptions and feelings towards returning to school. Examples include feelings of being too 125 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses old, inability to stand the pressure surrounding the academic environment, no interest in learning among other factors. Additional barriers that emerged from the data included barriers from employers of non - professional nurses. These barriers are in the form of lack of academic progression opportunities and challenges with obtaining study leave. The second additional barrier is problems arising from the management of healthcare facilities which are in the form of shortage of nurses and lack of organisational support towards continuing further education. [ All the findings, identified from the study are in line with the findings of previous studies that have been conducted in different countries to explore nurses’ perception, motivators, barriers and measures to continuing formal education. On the whole, the conceptual framework which guided the study, which is the Cross (1981) Chain of Response Model aided the researcher in answering the research questions. As the study showed that, because non - professional nurses have a positive perception about continuing formal education, the majority of the study participants are eager to pursue further studies amid the numerous barriers that make it difficult for them to realise their dreams. They believed that engaging in continuing formal education would enable them to acquire more knowledge to their basic training in the profession, obtain a higher certificate, improve their care delivery skills, have an increase in their salaries as well as possess the ability to mentor others. [ Though the Cross (1981) chain of response model did not talk about measures to enhance adult participation in education, participants in this study suggested measures that could be implemented to promote the continuing formal education of non - professional nurses. The measures given by participants include clear and effective governmental policies on education; the need for educational programmes to meet the needs of non - professional nurses, collaboration between educational institutions and healthcare facilities on educational 126 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses opportunities and programmes, establishment of mentorship programmes and the need for organisations to support non - professional nurses in the pursuance of continuing formal education. 127 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses CHAPTER SIX SUMMARY, CONCLUSION AND RECOMMENDATION 6.0 Introduction This chapter presents the summary of the study, implications of the research findings to nursing practice, education and research. The chapter further explains the insight the researcher has gained from the study, limitations of the study, conclusions and recommendations. 6.1 Summary of the Study Education undoubtedly is essential for the growth of the individual, families and the nation as a whole. Nursing as a profession cannot thrive without it members engaging in continuing formal education to be abreast with current trends in the profession, as the profession is progressively evolving with research and technology. Thus, this study explored the experiences of non - professional nurses in their quest to pursue continuing formal education. The qualitative descriptive design was used to explore the experiences of non - professional nurses’ with continuing formal education. The study specifically looked at their perceptions, motivation and barriers to continuing formal education. The measures to promote their engagement in continuing formal education was also examined. The purposive sampling technique was used to recruit twenty - three non - professional nurses who have served for at least five years in the health sector and worked at the Pantang hospital. The participants were in three categories; namely, non - professional nurses who have completed continuing formal education, non - professional nurses who are in school and non - professional nurses who are yet to enroll in a continuing formal education. A semi - structured interview guide with open ended questions based on the objectives of the study and the constructs of the Cross Chain of Response Model was designed to elicit responses from participants (Cross, 1981). The interview guide was pretested with non - professional nurses 128 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses who have similar characteristics with study participants and work at the Kwahu Government hospital, Atibie in the Eastern Region of Ghana. Permission was sought from the management of Pantang Hospital to recruit participants from the facility. The researcher was introduced to non - professional nurses who were briefed on the purpose and objectives of the study and information sheets were given to participants for further clarification on the research. Non - professional nurses who met the inclusion criteria and consented to be part of the study were recruited as participants. Participation in the study was solely voluntary with no coercion. [ An appropriate day, time and place were scheduled with each participant. Interviews were conducted with participants and their permission sought to record the interview session and all major happenings of the day were recorded in a field diary. Each interview session lasted for about forty - five minutes and data was read severally and transcribed at the end of the session. The interviews got better as data collection continued. Saturation was achieved with the twenty - third participant when no new information was added to the responses. Data were managed by ensuring that demographic data of participants were separated from the transcript and filed appropriately. Each transcript was numbered and given pseudonyms to protect the identity of study participants. The thematic content analysis was used to analyse the data. Data were read and re - read to make meaning of the data and coding done to identify codes and sub - themes. The Nvivo software was employed to group themes and sub - themes and quotations identified to support the themes and sub - themes. After the themes and sub - themes with quotations were identified, the transcripts, demographic data, field diary and audio recordings were kept safe electronically with only the researcher and her supervisors who could only have access to it. 129 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses The four main themes that guided the study were the perception of continuing formal education, motivational factors for pursuing continuing formal education, barriers to continuing formal education and measures to enhance continuing formal education. In analysing the data under the theme “perception of continuing formal education”; four sub - themes emerged from the data. The findings from the study showed that non - professional nurses have a positive perception about continuing formal education. The nurses perceived engaging in continuing formal education as important to both their professional and personal development. The nurses also held the perception that, by pursuing continuing formal education, they could acquire additional knowledge to their basic knowledge, be exposed to current trends in the nursing profession which will aid them in meeting the diverse needs of their clients. Regarding how continuing formal education contributes to the personal development of the non - professional nurses’ life, the nurses opined that by pursuing further studies, they would be promoted to the next rank which is likely to come with an increase in salary implying that they could take good care of their families. The theme motivation to continuing formal education has eight sub - themes and explains the fact that, though challenges exist to make it difficult for non - professional nurses to return to school, non - professional nurses are motivated by several factors to pursue further studies. The motivational factors identified from this study are self - determination, low academic qualification, progression in life, employer’s recognition for higher academic qualifications than experience, lack of professional competencies, ambition and the drive for career options, practicing outside one’s job description, lack of respect and influence of mentors and role models. The theme “barriers to continuing formal education” have twelve sub - themes emerging from the data. 130 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses The study showed that the barriers which deter non - professional nurses from returning to school include family responsibilities, barriers from educational institutions, dispositional barriers and barriers from employers and management of healthcare facilities. Barriers originating from family responsibilities include marriage, caring for one’s family, pregnancy and financial obligations. Barriers from educational institutions responsible for the education of non - professional nurses are difficulty in getting authentic information about available educational programmes, lack of recognition of educational needs, lack of counseling services in schools and the need for non - professional nurses to improve their senior high school grades before they could pursue existing continuing formal educational programmes. [ Dispositional barriers include feeling too old to learn, lack of readiness to return to school and the inability to stand the challenging academic environment. All the above mentioned barriers are consistent with the Cross Chain of Response Model (Cross, 1981). Additional barriers that emerged from the data include barriers arising from the employer of non - professional nurses which are in the form of lack of academic progression opportunities and challenges with obtaining study leave. The second additional barrier had to do with problems with management of healthcare facilities where non - professional nurses’ work and they include shortage of nurses and lack of organisational support for learning. [ Measures suggested by non - professional nurses to enhance their participation in continuing formal education are clear educational policies on continuing formal education, continuing formal education should be made mandatory for all non - professional nurses, the need for educational programmes to be designed to meet the needs of non - professional nurses. Finally, non - professional nurses highlighted the need for collaboration among all stakeholders responsible for their education to develop appropriate strategies to enhance their continuing formal education. 131 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses [ The findings identified from the study, are in line with the Cross chain of response model which guided the study and also affirms the findings of previous studies. According to Cross’ model, a host of factors do influence the adult’s decision to participate in an educational programme or not. These factors include the adult’s self - perception and attitudes about education, the value he or she places on education, the expectation that participation will meet goals, life transitions, opportunities and barriers to education and the information an adult gets concerning an educational programme all influence his or her decision to engage in an educational programme or not. Similarly, this study found that non - professional nurses are eager to participate in continuing formal education because they have a positive perception about returning to school and believes that participation in an educational programme will help them acquire more knowledge, be exposed to current trends in the profession and build on their professional competencies. [Although non - professional nurses admitted there are barriers which deter their engagement in continuing formal education. Participants suggested measures that could be implemented to enhance their involvement in further studies. 6.2 Implications of the Research The findings of the study have implication for nursing practice, research and education. 6.2.1 Implication for Nursing Practice Continuing formal education should be viewed as a tool for building the professional competencies of non - professional nurses to enable them meet the diverse health needs of their clients. Hence, much attention should be focused on ensuring that, every non - professional nurse engages in continuing formal education after serving for five years as stipulated by the Ghana Health Service Human Resource training policy. Management of healthcare facilities 132 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses within which non - professional nurses work should come to the realization that the health sector is no longer static but is dynamic with the advent of technology and research, so the need for non - professional nurses to pursue continuing formal education in order to meet up this challenge. In addition to the era of technological advancement, clients who patronize healthcare services are aggressively demanding quality and competent services, signaling the need for highly trained and well equipped personnel to continually satisfy the aggressive demands of clients. Furthermore, when clients are satisfied with their health needs, the image of healthcare facilities would be lifted, nurses would be satisfied and this would lead to staff retention in our various health facilities. 6.2.2 Implication for Nursing Education Continuing formal education of the non - professional nurse should be considered as the collective responsibility of all stakeholders notably government (Ministry of Health), educational institutions, the Nursing and Midwifery Council of Ghana, management of healthcare facilities and the non - professional nurse. Appropriate strategies should therefore be developed to encourage non - professional nurses to pursue continuing formal education. In addition, educational programmes should be flexible to accommodate the individual needs of non - professional nurses, where their experiences could be fully utilized. Furthermore, creation of a conducive learning environment with support structures such as counseling services and hostel facilities are essential in encouraging non - professional nurses to be interested in returning to school for further studies. 6.2.3 Implication for Nursing Research The youthful age of non - professional nurses require that more research are conducted to find out measures that can be put in place to promote their engagement in continuing formal education. Additional research is also needed to find out what management of healthcare facilities can do to boost the morale of non - professional nurses to return to school. 133 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Furthermore, research are needed to explore the different motives with which non - professional nurses would like to return to school to pursue further studies as this would guide educational planners in designing programmes that would meet the needs of non - professional nurses as learners. For continuing formal education of non - professional nurses to be held paramount, research is also required to find out whether non - professional nurses are able to implement the knowledge acquired from pursuing continuing formal education within clinical settings and the extent to which continuing formal education impacts on nursing practice. 6.3 Insight Gained From the Study Conducting the research entitled “Continuing formal education for nurses: Exploring the experiences of non - professional nurses has been a great experience for the researcher. The researcher was privileged to research into the experiences of nurses on continuing formal education. As a researcher, I was personally motivated to study the experiences of non - professional nurses on continuing formal education because I realized that many studies have been conducted on professional nurses and continuing formal education, but there is paucity of literature on whether non - professional nurses would pursue further studies or not. Their perceptions, motivators and barriers to continuing formal education have not been explored. The descriptive qualitative research design allowed the researcher to explore and understand the experiences of non - professional nurses on continuing formal education. Being a novice researcher, this research has enabled the researcher to know that acquiring in - depth explanation of peoples’ beliefs, perceptions and rationale for carrying out certain activities, requires that the qualitative research design is used as this offers the researcher the opportunity to really understand the phenomenon under study from the perspective of individual’s experiencing it in their natural setting. The researcher has also gained the understanding that carrying out research involves proper planning and conscientious management of time and resources. The researcher acknowledges the importance of obtaining ethical clearance from the 134 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses institutionalised review board to ensure that the rights of research participants are maintained without exploitation and violation. [ The data gathering process, starting from institutional approval to data collection has boosted the confidence and communication skills of the researcher. Furthermore, employing the thematic content analysis was a great experience, which required that the researcher patiently read and re - read a chunk of data to identify codes, themes and sub - themes from the data. The researcher was finally intrigued by the findings of the research, which showed that non - professional nurses are not satisfied with their basic knowledge and qualification in the nursing profession; hence their desire to be given the opportunity to further their studies to enhance their professional and personal development in life. The discussion section of the research also enabled the researcher to know how her study findings corroborated with the findings of other studies conducted to explore the perception, motivators, barriers and measures encountered by nurses in their quest to pursue continuing formal education in different countries. In conclusion, this academic writing has exposed the researcher to the rudiments of carrying out research by looking for a research area of interest, a researchable topic, writing a proposal and coming out with a thesis. The acquired knowledge will help the researcher in identifying problems at the clinical area and apply the research techniques gained in carrying out this research in resolving them. 6.4 Limitations of the Study The findings of this study showed that non - professional nurses admit they possess basic knowledge in the nursing profession which hinders their ability to offer quality healthcare services to their clients, therefore the need for them to be given the opportunity to pursue further studies. Non - professional nurses in this study also suggested prudent measures that can be put in place to enhance their engagement in continuing formal education. Though the study 135 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses identified very important findings of non - professional nurses’ perception, motivations, barriers and measures to promote their continuing formal education, there are limitations to this study. The first limitation is the low number of male non - professional nurses’ participation in the study. Only one male non - professional nurse participated in the study and this is likely to create some biases in the findings of the study. Secondly, the researcher’s association with some non - professional nurses on the ward for a period of six years may have an influence on the study’s findings. 6.5 Conclusions of the Study In conclusion, the study employed the qualitative descriptive design in exploring the experiences of non - professional nurses on continuing formal education. Twenty - three study participants which included non - professional nurses who have completed continuing formal education, non - professional nurses who are on a programme of study and non - professional nurses who are yet to return to school for further studies. The study sought to find out the perceptions, motivations and barriers to continuing formal education of non - professional nurses. Measures to enhance the continuing formal education of non - professional nurses was also examined. [ The Cross Chain of Response Model which explains why the adult learner would participate in an educational programme guided the study. The findings of the study showed that non - professional nurses have a positive perception about returning to school to pursue further studies as they acknowledge that their basic education is an obstacle to their delivery of quality health services to their clients. Amid challenges encountered at the workplace and from the general public, the study also revealed that non - professionals are self - determined, committed and dedicated to pursuing continuing formal education. Though the findings of this study were consistent were the findings of previous studies. Additional findings that emerged from the 136 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses data were: (1) non - professional nurses are motivated to pursue further studies because they find themselves practicing outside their job description. (2) The barriers to continuing formal education also showed that lack of academic progression opportunities is a major barrier which deters non - professional nurses from pursuing further studies. Deducing from the measures suggested by non - professional nurses in this study it is imperative that efficient partnership among all stakeholders responsible for the continuing formal education of non - professional nurses where each stakeholder’s aspirations, perceptions and restrictions are effectively addressed will be a better way of enhancing the continuing formal education of non - professional nurses. 6.6 Recommendations of the Study The following recommendations are made based on the findings of the study: 1. All stakeholders responsible for the continuing formal education of non - professional nurses should collaborate in designing appropriate strategies to promote continuing formal education of non - professional nurses. 2. Management of healthcare facilities should workout staff development plans with their staff members to ensure that non - professional nurses working in their healthcare facilities return to school for further studies. 3. There should be the creation of an organisational culture that supports nurses’ engagement in continuing formal education and lifelong learning. 4. Counselling services should be provided in educational institutions and workplaces for nurses to encourage them to go back to school. [ 5. Orientation programmes for non - professional nurses when they are newly employed should capture career progression of staff and available opportunities for continuing formal education. The number of years non - professional nurses are to serve before 137 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses returning to school for further studies, what educational programmes are available for them, how they can be assessed and the support systems available to aid their successful completion of their programmes of study should be captured in such orientation programmes. 6. There should be the introduction of more online, weekends and sandwich programmes which will make continuing formal education more accessible to non - professional nurses. 7. There should be a revision in education of non - professional nurses so that educational programmes could be designed to meet their learning needs. 8. Finally, there is the need for more mentors and role models in the nursing profession to train non - professional nurses to emulate their fine examples to enable them to excel to greater heights in the profession. 138 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses REFERENCES Aiga, H., & Kuroiwa, C. (2006). Quantity and distribution of continuing professional education opportunities among healthcare workers in Ghana. The Journal of Continuing Education in Nursing. Retrieved from http://www.healio.com/nursing/journals/jcen/2006-11-37-6/%257B6ab07198-ba9b- 43e5-a2c0-7732f3b90ff7%257D/quantity-and-distribution-of-continuing-professional- education-opportunities-among-healthcare-workers-in-ghana Alamri, M., & Sharts-Hopko, N. C. (2015). Motivational Factors and Barriers Related to Saudi Arabian Nurses’ Pursuit of a Bachelor of Science in Nursing Degree. Nursing Education Perspectives, 36(3), 157–162. https://doi.org/10.5480/14-1376 Altmann, T. K. (2012). Nurses’ Attitudes Toward Continuing Formal Education: A Comparison by Level of Education and Geography. Nursing Education Perspectives, 33(2), 80–84. https://doi.org/10.5480/1536-5026-33.2.80 American Association of Colleges of Nursing [AACN]. (2010). The Future of Higher Education in Nursing.Annual Report. American Nurses Association& National Nursing Staff Development Organisation 2010. (2010). Nursing Professional development:Scope and Standards of practice. Silver Spring, MD: American Nurses Association. Aziato, L., Kwashie, A., Korsah, K. A., & Naab, F. (2014). Footprints of the Nursing Profession: Current Trends and Emerging Issues in Ghana. Ghana: Sub-Saharan Publishers. Retrieved from https://books.google.com.gh/books?id=BTkKBAAAQBAJ&printsec=frontcover&sourc e=gbs_ge_summary_r&cad=0#v=onepage&q&f=false Back, L. (2012). Expert Voices . In S.E. Baker & R . Edwards. How many qualitative interviews is enough. National Center for Research Methods Review Discussion Paper. Badu-Nyarko, S. K. (2015). Survey of continuing professional education of nurses in Ghana. International Journal of Education Studies, 2(2), 71–81. Baxter, P., DiCenso, A., Donald, F., Martin-Misener, R., Opsteen, J., Chambers, T., … DiCenso, A. (2013). Continuing education for primary health care nurse practitioners in Ontario, Canada. Nurse Education Today, 33(4), 353–357. https://doi.org/10.1016/j.nedt.2012.07.018 Bell, S. A., Rominski, S., Bam, V., Donkor, E., & Lori, J. (2013). Analysis of nursing education in Ghana: Priorities for scaling-up the nursing workforce. Nursing & Health Sciences, 15(2), 244–249. https://doi.org/10.1111/nhs.12026 Berings, M. (2006). On-The-Job Learning Styles\nConceptualization and Instrument Development or the Nursing Profession. Retrieved from http://www.narcis.nl/publication/RecordID/oai:tilburguniversity.edu:publications%2Faf 06b297-707c-4000-8d46-a203b9aaff7e Blythman, M., & Orr, S. (2002). A joined up policy approach to student support. Retrieved from http://ualresearchonline.arts.ac.uk/id/eprint/7378 Böhmig, C. (2010). Ghanaian nurses at crossroads:managing expectations on a medical ward. Downloaded from UvA-DARE, the institutional repository of the University of Amsterdam (UvA). Retrieved from http://hdl.handle.net/11245/2.73386 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa Brekelmans, G., F. Poell, R., & van Wijk, K. (2013). Factors influencing continuing professional development. European Journal of Training and Development, 37(3), 313– 325. https://doi.org/10.1108/03090591311312769 Brekelmans, G., Maassen, S., Poell, R. F., Weststrate, J., & Geurdes, E. (2016a). Factors 139 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses influencing nurse participation in continuing professional development activities: Survey results from the Netherlands. Nurse Education Today, 40, 13–19. https://doi.org/10.1016/j.nedt.2016.01.028 Brekelmans, G., Maassen, S., Poell, R. F., Weststrate, J., & Geurdes, E. (2016b). Factors influencing nurse participation in continuing professional development activities: Survey results from theNetherlands. Nurse Education Today, 40, 13–19. https://doi.org/10.1016/j.nedt.2016.01.028 Burton, K., Lloyd, M. G., & Griffiths, C. (2011a). Barriers to learning for mature students studying HE in an FE college. Journal of Further and Higher Education, 35(1), 25–36. https://doi.org/10.1080/0309877X.2010.540231 Burton, K., Lloyd, M. G., & Griffiths, C. (2011b). Barriers to learning for mature students studying HE in an FE College. Journal of Further and Higher Education, 35(1), 25–36. https://doi.org/http://dx.doi.org/10.1080/0309877x.2010.540231 Cathro, H. (2011). Pursuing graduate studies in nursing education: driving and restraining forces. Online Journal of Issues in Nursing. https://doi.org/10.3912/OJIN.Vol16No03PPT02 Chong, M. C., Francis, K., Cooper, S., & Abdullah, K. L. (2014). Current Continuing Professional Education Practice among Malaysian Nurses. Nursing Research and Practice, 2014, 126748. https://doi.org/10.1155/2014/126748 Clark, E., Draper, J., & Rogers, J. (2015). Illuminating the process: Enhancing the impact of continuing professional education on practice. Nurse Education Today, 35(2), 388–394. https://doi.org/10.1016/j.nedt.2014.10.014 Cohen, L., Manion, L., & Morrison, K. (2005). Research methods in education ((5th ed. )). New York: Routledge Falmer. Coventry, T. H., Maslin-Prothero, S. E., & Smith, G. (2015a, December). Organizational impact of nurse supply and workload on nurses continuing professional development opportunities: An integrative review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.12724 Coventry, T. H., Maslin-Prothero, S. E., & Smith, G. (2015b, December). Organizational impact of nurse supply and workload on nurses continuing professional development opportunities: An integrative review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.12724 Creswell, J. W. (2007). Qualitative inquiry & research design :Choosing among five approaches ((2nd ed)). Thousand Oaks, CA: Sage. Cross, K. P. (1981). Adults as Learners: Increasing Participation and Facilitating Learning. Journal of Higher Education (Vol. 54). Retrieved from http://eric.ed.gov/?id=ED200099 Duffy, M. T., Friesen, M. A., Speroni, K. G., Swengros, D., Shanks, L. A., Waiter, P. A., & Sheridan, M. J. (2014). BSN Completion Barriers, Challenges, Incentives, and Strategies. JONA: The Journal of Nursing Administration, 44(4), 232–236. https://doi.org/10.1097/NNA.0000000000000054 Eslamian, J., Moeini, M., & Soleimani, M. (2015). Challenges in nursing continuing education: A qualitative study. Iranian Journal of Nursing and Midwifery Research, 20(3), 378–386. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26120340 Fentahun, N., & Molla, A. (2012). Determinants of and opportunities for continuing education among health care professionals in public health care institutions in Jimma township, Southwest. Advances in Medical Education and Practice, 3, 89–96. https://doi.org/10.2147/AMEP.S35289 Fentahun, N., & Molla, a. (2012). Determinants of and opportunities for continuing education among health care professionals in public health care institutions in Jimma township, Southwest. Advances in Medical Education and Practice, 89–96. Retrieved 140 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses from https://www.dovepress.com/getfile.php?fileID=13991 Fitzgerald, S., Beattie, B., Carter, L., & Caswell, W. (2014). Reports of Practice, 40(1), 1–13. Gao, L., Chan, S. W., & Cheng, B. (2011). Republic of China : a discussion paper, (August 2009). https://doi.org/10.1111/j.1365-2648.2011.05828.x Gorczyca, C. (2013). Factors influencing the pursuit of graduate education in registered nurses: exploring the motivators and barriers. Retrieved from https://open.library.ubc.ca/cIRcle/collections/ubctheses/24/items/1.0165658 Gould, D., Papadopoulos, I., & Kelly, D. (2014). Tutors’ opinions of suitability of online learning programmes in continuing professional development for midwives. Nurse Education Today, 34(4), 613–618. https://doi.org/10.1016/j.nedt.2013.06.006 Govranos, M., & Newton, J. M. (2014). Exploring ward nurses’ perceptions of continuing education in clinical settings. Nurse Educ Today. https://doi.org/10.1016/j.nedt.2013.07.003 Govranos, M., & Newton, J. M. (2014). Nurse Education Today Exploring ward nurses â€TM perceptions of continuing education in clinical settings. YNEDT, 34(4), 655–660. https://doi.org/10.1016/j.nedt.2013.07.003 Hutchinson, L., Mitchell, C., & St John, W. (2011). The transition experience of enrolled nurses to a Bachelor of Nursing at an Australian University. Contemporary Nurse, 38(1– 2), 191–200. https://doi.org/10.5172/conu.2011.38.1-2.191 Ikenwilo, D., & Skåtun, D. (2014). Perceived need and barriers to continuing professional development among doctors. Health Policy, 117(2), 195–202. https://doi.org/10.1016/j.healthpol.2014.04.006 Institute of Medicine. (2010). The Future of Nursing: Leading Change,Advancing Health. Washington,DC: The National Academies Press. Institute of Medicine. (2011). Future of Nursing: Leading Change, Advancing Health. Washington,DC: The National Academies Press. Retrieved from http://www.nap.edu/Catalog.php?record.id=12956#toc Karaman, S. (2011). Nurses’ perception of online continuing education. BMC Medical Education, 11, 86. Retrieved from http://www.biomedcentral.com/1472-6920/11/86 Karaman, S. (2011). Nurses’ perceptions of online continuing education. https://doi.org/10.1186/1472-6920-11-86 Kvalve, S. (2007). Doing interviews. Thousand Oaks, CA: Sage. Lahti, M., Hätönen, H., & Välimäki, M. (2014, January). Impact of e-learning on nurses’ and student nurses knowledge, skills, and satisfaction: A systematic review and meta- analysis. International Journal of Nursing Studies. University of York, Centre for Reviews and Dissemination. https://doi.org/10.1016/j.ijnurstu.2012.12.017 Lerner, N. B., Resnick, B., Galik, E., & Russ, K. G. (2010). Advanced nursing assistant education program. Journal of Continuing Education in Nursing, 41(8), 356–62. https://doi.org/10.3928/00220124-20100401-10 Levett-Jones, T. (2005). Continuing education for nurses: a necessity or a nicety? The Journal of Continuing Education in Nursing. Retrieved from http://www.healio.com/nursing/journals/jcen/2005-9-36-5/%257Bd119bd2e-079a-49c6- 9be2-02e94ee87b6d%257D/continuing-education-for-nurses-a-necessity-or-a-nicety Lincoln, Y. S., & Guba, E. (1985). Establishing Trustworthiness. In Naturalistic Inquiry (pp. 289–331). https://doi.org/10.1177/1473325006070288 Maneval, R. E., & Teeter, M. M. (2010). The student perspective on RN-Plus-10 legislation: A survey of associate degree and diploma nursing program students... with discussion. Nursing Education Perspectives, 31(6), 358–361. https://doi.org/10.1043/1536-5026- 31.6.358 Morse, J. M., Barrett, M., Mayan, M., Olson, K., & Spiers, J. (2002). Verification Strategies 141 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses for Establishing Reliability and Validity in Qualitative Research. International Journal of Qualitative Methods, 1(2), 13–22. https://doi.org/10.1063/1.2011328 Muliira, J. K., Etyang, C., Muliira, R. S., & Kizza, I. B. (2012a). Nurses’ Orientation Toward Lifelong Learning: A Case Study of Uganda’s National Hospital. The Journal of Continuing Education in Nursing, 43(2), 90–96. https://doi.org/10.3928/00220124- 20111003-03 Muliira, J. K., Etyang, C., Muliira, R. S., & Kizza, I. B. (2012b). Nurses{&}apos; orientation toward lifelong learning: a case study of Uganda{&}apos;s national hospital. Journal of Continuing Education in Nursing, 43(2), 90–96. https://doi.org/10.3928/00220124- 20111003-03 Munro, K. M. (2008). Continuing professional development and the charity paradigm: Interrelated individual, collective and organisational issues about continuing professional development. Nurse Education Today, 28(8), 953–961. https://doi.org/10.1016/j.nedt.2008.05.015 Nalle, M. A., Wyatt, T. H., & Myers, C. R. (2010). Continuing Education Needs of Nurses in a Voluntary Continuing Nursing Education State. The Journal of Continuing Education in Nursing, 41(3), 107–115. https://doi.org/10.3928/00220124-20100224-03 Neergaard, M. A., Olesen, F., Andersen, R. S., & Sondergaard, J. (2009). Qualitative description -- the poor cousin of health research? BMC Medical Research Methodology, 9(1), 1–5. https://doi.org/10.1186/1471-2288-9-52 Ni, C., Hua, Y., Shao, P., Wallen, G. R., Xu, S., & Li, L. (2014). Continuing education among Chinese nurses: A general hospital-based study. Nurse Education Today, 34(4), 592–597. https://doi.org/10.1016/j.nedt.2013.07.013 Nsemo, A. D., John, M. E., Etifit, R. E., Mgbekem, M. A., & Oyira, E. J. (2013). Clinical nurses’ perception of continuing professional education as a tool for quality service delivery in public hospitals Calabar, Cross River State, Nigeria. Nurse Education in Practice, 13(4), 328–334. https://doi.org/10.1016/j.nepr.2013.04.005 Orsolini-Hain, L., & Waters, V. (2009). Education evolution: a historical perspective of associate degree nursing. The Journal of Nursing Education, 48(5), 266–271. https://doi.org/10.9999/01484834-20090416-05 Osterman, P. L., Asselin, M. E., & Cullen, H. A. (2009). Returning for a baccalaureate: a descriptive exploratory study of nurses’ perceptions. Journal for Nurses in Staff Development - JNSD, 25(United States PT-Journal Article PT-Research Support, Non- U.S. Gov’t LG-English DC-20090608), 109–117. https://doi.org/10.1097/NND.0b013e3181a566be Perfetto, L. M. (2015). Facilitating educational advancement of RNs to the baccalaureate: What are they telling us? Nursing Education Perspectives, 36(1), 34–41. https://doi.org/10.5480/13-1161.1 Plunkett, R. D., Iwasiw, C. L., & Kerr, M. (2010). The Intention to Pursue Graduate Studies in Nursing: A Look at BScN Students’ Self-Efficacy and Value Influences. International Journal of Nursing Education Scholarship, 7(1). https://doi.org/10.2202/1548- 923X.2031 Polit, D. F., Beck, C. F., & Hungler, B. P. (2001). Essentials of Nursing research:Methods Appraisal and Utilization. Retrieved from https://scholar.google.com/scholar?q=Polit%2C+D.+F.%2C+Beck%2C+T.+C.%2C+%2 6+Hungler%2C+B.+P.+%282001%29.+Essentials+of+nursing+research%3A+Methods %2C+appraisal+and+utilization.+%285th+ed.%29.+J.+P.+Lippincott%2C+Philadelphia %2C+PA.&btnG=&hl=en&as_sdt=0%2C Pool, I. A., Poell, R. F., Berings, M. G. M. C., & ten Cate, O. (2016). Motives and activities for continuing professional development: An exploration of their relationships by 142 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses integrating literature and interview data. Nurse Education Today, 38, 22–28. https://doi.org/10.1016/j.nedt.2016.01.004 Pool, I., Poell, R., & Ten Cate, O. (2013). Nurses’ and managers’ perceptions of continuing professional development for older and younger nurses: A focus group study. International Journal of Nursing Studies, 50, 34–43. https://doi.org/10.1016/j.ijnurstu.2012.08.009 Power, A., Grammatiki, A., Bates, I., Mc Kellar, S., Johnson, B. J., Diack, H. L., … Hudson, S. A. (2011). Factors affecting the views and attitudes of Scottish pharmacists to continuing professional development. International Journal of Pharmacy Practice, 19(6), 424–430. https://doi.org/10.1111/j.2042-7174.2011.00135.x Quaicoe-Duhol, R. (2014). Stop training certificate nurses-GRNA. Daily Graphic. Retrieved from http://graphic.com.gh/news/health/1569-stop-training-certificate nurses.grna.html.Graphic Online Richards, L., & Potgieter, E. (2010). Perceptions of registered nurses in four state health insititutions on continuing formal education. Curationis, 33(2), 41–50. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21469515 Rodrigo, O., Caïs, J., & Monforte-Royo, C. (2017). Transfer of nurse education to universities under a model of person-centred care: A consequence of changes in Spanish society during the democratic transition. Nurse Education Today, 54, 21–27. https://doi.org/10.1016/j.nedt.2017.04.006 Ross, K., Barr, J., & Stevens, J. (2013). Mandatory continuing professional development requirements: what does this mean for Australian nurses. BMC Nursing, 12(1), 9. https://doi.org/10.1186/1472-6955-12-9 Rouse, S. M., & Rooda, L. a. (2010). Factors for attrition in an accelerated baccalaureate nursing program. The Journal of Nursing Education, 49(6), 359–62. https://doi.org/10.3928/01484834-20100217-05 Sarver, W., Cichra, N., & Kline, M. (2015). Perceived Benefits, Motivators, and Barriers to Advancing Nurse Education: Removing Barriers to Improve Success. Nursing Education Perspectives, 36(3), 153–156 4p. https://doi.org/10.5480/14-1407 Schweitzer, D. J., & Krassa, T. J. (2010). Deterrents to Nurses’ Participation in Continuing Professional Development: An Integrative Literature Review. The Journal of Continuing Education in Nursing, 41(10), 441–447. https://doi.org/10.3928/00220124-20100601-05 Searle, C., Human, S., & Mogotlane, S. (2009). Professional practice: A Southern African nursing perspective. Retrieved from https://scholar.google.com/scholar?hl=en&q=SEARLE%252C+C%253B+HUMAN%25 2C+S+%2526+MOGOTLANE%252C+SM+2009%253A+Professional+practice.+A+So uthern+African+nursing+perspective.+5th+edition.+Johannesburg%253A+Heinemann+ Publishers+%2528Pty%2529+Ltd.+SHADER%252C&btnG=&as_sdt=1%252C5&as_s dtp= Shahhosseini, Z., & Hamzehgardeshi, Z. (2015). The facilitators and barriers to nurses’ participation in continuing education programs: a mixed method explanatory sequential study. Global Journal of Health Science, 7(3), 184–93. https://doi.org/10.5539/gjhs.v7n3p184 Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(February), 63–75. https://doi.org/10.1111/j.1744- 618X.2000.tb00391.x Singh, M. (2001). No TitleIntroduction, in reinserting the public good into higher education council for higher education discussion series. Washington, D.C.: The World Bank. Skela-Savi??, B., & Kiger, A. (2015). Self-assessment of clinical nurse mentors as dimensions of professional development and the capability of developing ethical values 143 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses at nursing students: A correlational research study. Nurse Education Today, 35(10), 1044–1051. https://doi.org/10.1016/j.nedt.2015.04.003 Skela-Savič, B., & Kiger, A. (2015). Self-assessment of clinical nurse mentors as dimensions of professional development and the capability of developing ethical values at nursing students: A correlational research study. Nurse Education Today, 35(10), 1044–1051. https://doi.org/10.1016/j.nedt.2015.04.003 Turner, D. W. (2010). A practical guide for novice investigations. The Qualitative Report, 15(3), 754–760. Retrieved from http://www.nova.edu/sss/QR/QR15/qid.pdf Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implecations for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398–405. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/nhs.12048/full Warren, J., & Mills, M. (2009). Motivating registered nurses to return for an advanced degree. Journal of Continuing Education in Nursing, 40(5), 200–207. https://doi.org/10.3928/00220124-20090422-01 Witt, C. (2011). Continuing education: a personal responsibility. Advances in Neonatal Care: Official Journal of the. Retrieved from http://europepmc.org/abstract/med/22123340 World Bank. (2005). Meeting the challenge of Africa’s development: A World bank group action plan processed. Washington, D.C.: World Bank. World Bank/UNESCO. (2000). Higher education in developing countries: Peril and promise. Washington, D.C.: The World Bank.Task force on higher education and society. Retrieved from http://www.tfhe.net/report/downloads/report/whole.pdf. 144 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses APPENDICE Appendix A - Interview Guide 145 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 146 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 147 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Appendix B - Individual Consent Form 148 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 149 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 150 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses 151 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Appendix C - General Profile of Participants Variables Non Non Professional Non Professional Total Professional Nurses who have Nurses who are Nurses in Completed Not yet in School School School Number of participants 9 6 8 23 Number of Males 0 1 0 1 Number of Females 8 5 9 22 Age of Participants 20 - 30years 2 2 5 9 30 - 39 years 6 4 4 14 Marital Status Married 6 4 4 14 Divorced 0 0 0 0 Single 3 2 4 9 Programmes pursued by Participants Bachelor of Science in 1 1 0 2 Nursing Community Psychiatry 0 2 0 0 Certificate Post Basic 8 2 0 10 Midwifery Health Promotion 0 1 0 1 Age of Children of Participants 0 - 2 years 4 2 2 8 3 - 5 years 2 2 2 6 Years of Service 5 - 9 years 8 4 8 20 10 - 14years 1 2 0 3 152 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Appendix D - Summary of Themes Main themes Subthemes Perception of continuing formal education Acquisition of additional knowledge and upgrading Improvement in care delivery Exposure to current trends in nursing Raised economic standards Motivational factors for Pursuing continuing formal education Self determination Lack of professional competencies Progression in life Employers’ recognition for higher academic qualification than working experience Ambition and drive for better career options Practicing outside ones’ job description Lack of respect Influence of mentors’ and role models Barriers to continuing formal education Situational barriers Family responsibilities Financial obligations Institutional barriers Lack of authentic information on educational Programmes Lack of recognition of educational needs The need to improve senior high school grades Lack of counseling services in schools Dispositional barriers Inability to cope with schooling experiences Barriers from employer Lack of academic progression opportunities Challenges with study leave Challenges arising from managers of Shortage of nurses healthcare facilities Lack of organizational support Measures to enhance continuing formal education Government policy on education of non - professional Nurses Development of educational programmes for non professional nurses Collaboration between educational institutions and healthcare facilities Establishment of mentorship programmes Organizational support for continuing formal education 153 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Appendix E - Ethical Approval Letter 154 University of Ghana http://ugspace.ug.edu.gh Continuing Formal Education for Non - Professional Nurses Appendix F - Introductory Letter 155