Resumen de Percepciones de las enfermeras sobre la educación continua en enfermería: factores motivacionales y barreras
Argyro Tsirigoti
The concept of human capital, as introduced by economist Theodore William Schultz in 1961, highlights the importance of investing in education, training, and healthcare to enhance the skills and abilities of individuals, much like investments in physical capital. Schultz's work shifted the focus of economics from traditional physical assets to human knowledge and skills as drivers of economic growth. In line with this, governments worldwide prioritize raising human capital levels through formal education and lifelong learning, which is critical in maintaining a competitive edge in the modern knowledge-based economy. In many ways it is more useful not to consider the human capital from the education side, but from the side of learning, the lifelong learning process (OEDC, n.d.).
Lifelong learning and adult education are integral to fostering a competitive and inclusive society, particularly in Europe. Since the Bologna Declaration of 1999, European countries have collaborated to harmonize higher education systems, emphasizing mobility, mutual recognition of qualifications, and ensuring quality assurance across the continent. This initiative aims to cultivate a "Europe of Knowledge" where adult education supports employability, cultural integration, and democratic values. The European Higher Education Area (EHEA) further promotes these objectives, making lifelong learning a key component of building a knowledge-based economy that enhances both individual capabilities and societal cohesion (EHEA, 2010).
In Greece, lifelong learning became relevant in the 19th century, as efforts to address illiteracy emerged. Over time, economic, social, and technological changes have made adult education an essential part of social inclusion and equality (Vergidis, 2003). Greece's shift from a migrant-sending to a migrant-receiving country, along with urbanization and societal changes, has made continuous education even more vital for integrating individuals into modern life (Lianos & Cavounidis, 2012). These trends underscore the necessity of lifelong learning in maintaining equality and responding to rapid global developments in a country where historically excluded groups now require greater inclusion through education (Vergidis, 2005).
The importance of Continuing Education for nurses has been increasingly emphasized in the nursing education literature since the beginning of the profession. It is an important process in learning due to the unexpected growth in professional knowledge, rapid changes in the healthcare system and the changes in nurses' roles (Glazer, 1999; Brunt, 2003). The requirement for nurses to participate in Continuing Professional Development differs between European countries and elsewhere in the world can be mandatory or voluntary (Pool et al.,2016).
Health care professionals need to update their skills regularly and continuing education enables the renewal and updating of skills in health care settings. With the constant progress of medical and nursing science, as well as the evolving demands of modern society, there is a growing need for nurses to continuously update their knowledge and skills (Kotzampasaki, 2004). Greece records the highest number per capita of doctors between EU countries, partly because the figures include all licensed physicians and not only those who are professional active. On the other hand, it has the lowest number of nurses in relation to the population, but this number includes only nurses working in hospitals (European Commission, 2021) This thesis explores the development and significance of Continuing Education (CE) and Adult Education in the 20th century, highlighting their crucial role in facilitating personal and professional growth among adults. CE is characterized as a process that enables individuals to enhance their skills, obtain diplomas, and navigate evolving job markets, and is classified into formal, non-formal, and informal education (Dave, 1976). According to Jarvis (1995), lifelong learning is distinct from continuing education, as it encompasses informal, non-formal, and formal education, enabling individuals to continuously develop throughout their lives in response to societal changes.
Evolving responsibilities of nurses in response to changing hospital environments, highlight the increasing necessity for Continuing Professional Education (CPE) (Royal College of Nursing 2010; Drey et al., 2009). It addresses the expectation for nurses to be lifelong learners, though not all view CPE positively. A conceptual framework by Urbano et al. (1988) identifies various factors influencing nurses' participation in CPE, including personal beliefs, demographic characteristics, and professional needs. Key motivational orientations for engaging in CPE are categorized in five categories: (a) Professional improvement and development, (b) professional service, (c) learning and interaction with colleagues, (d) personal benefits and job security, and (e) professional commitment (Houle, 1961). Deci and Ryan (1985) explain that motivation can be understood as the driving force or inspiration that stems from both intrinsic and extrinsic sources. Brekelmans et al. (2016) suggest that the motivation of nurses for professional development arises from various needs and is connected to their reasons for engaging in development activities. The literature also highlights various barriers to continuing nursing education (CNE), including personal factors like time constraints, health issues, and emotional stress, as well as interpersonal obstacles such as lack of support from co-workers and family. Structural barriers, such as work commitments, high costs, poor scheduling, and lack of organizational support, also deter nurses from participating in CNE. Additionally, heavy workloads, staff shortages, and poor program quality or accessibility further discourage nurses from investing in their ongoing education (Ebrahimi et al., 2012; Shahhosseini & Hamzehgardeshi, 2015).
Continuing Professional Education (CPE) is divided into official and unofficial forms, encompassing both formal and informal learning to enhance nurses' knowledge and skills for maintaining licensure and competent practice, often through a blended learning approach (Hegney et al., 2010).
Online learning has become increasingly popular among healthcare professionals for professional development (Green & Huntington, 2017), with terms like e-learning, web-based learning, and distance learning referring to education where at least 80% of the course content is delivered via computer and the internet(Kentor, 2015).
The debate over the necessity of mandatory versus voluntary continuing education in health professions has been ongoing (Field, 2004), with some countries like the UK, Belgium, and Australia requiring Continuing Professional Development (CPD) for nurses to maintain their registration (Ross et al., 2013). Conversely, nations such as Sweden, the Netherlands, and Greece do not have a systematic approach to CPD, allowing participation to remain voluntary for nurses (Heath, 2018). Nursing education in Europe is shaped by a combination of guidelines and regulations from the World Health Organization (WHO), European law, and individual member state laws, with the European Higher Education Area (EHEA) and the European Union (EU) playing significant roles in creating a harmonized and transparent education system that enhances the mobility of students and professionals across European countries (Bokonjic et al., 2019).
In last recent years, a large amount of research has been conducted on the motivation of nurses in continuing education programs (DeSilets, 1995). The first research effort to standardize motivational factors for participation in CPE was conducted by Houle in 1961 and became a valuable tool guide for subsequent research efforts in this area (Panagiotopoulou & Brokalaki, 2012).O'Conor's 1979 study was one of the first to examine the motivations behind nurses' participation in continuing education, finding that they engaged in these programs to stay updated on professional practices and improve care quality, a result echoed in a larger follow-up study in 1982. In her 1995 study, DeSilets used the Participation Reasons Scale (PRS) to identify five key motivations for nurses to participate in continuing nursing education: professional improvement, professional practice, personal benefit, learning with colleagues, and professional commitment. The findings indicated that nurses are primarily driven to enhance their skills, maintain competence, and engage in continuous learning with peers. Nurses generally have positive attitudes toward continuing education (CE) and are interested in participating (Kubsch et al., 2003); however, various barriers to participation have been identified in the literature. Pioneering research by Scanlan and Darkenwald (1984) introduced the Deterrents Participation Scale (DPS), which revealed six dimensions of inhibitory factors affecting healthcare workers' participation: disengagement, lack of quality, family constraints, cost, lack of benefit, and work constraints, aligning with Cross's categories of inhibitory factors from 1981.
Methodology: There are two main types of methodological approach in the social sciences. The quantitative method, which evaluates the frequency of occurrence of the subject examined in numerical terms and the qualitative method which records not only the frequency, but also the causes.
In the present study, both methodological approaches were applied, estimating that this will enhance the reliability of findings and conclusions (Creswell & Clark, 2011).
The quantitative study was conducted using an electronic, self-completed questionnaire distributed to Greek professional nursing associations and individual nurse colleagues. The survey included demographic questions, a Participation Reasons Scale (PRS) to explore motivations for continuing education, a Deterrents Participation Scale (DPS) to assess barriers. The sample consisted of 154 nurses, predominantly female (85%), with a mean age of 36 years. Most respondents worked in the public sector (64.5%), with a median work experience of 10 years. Participants worked varying schedules, with 64.3% working 40-60 hours per week. Educational backgrounds varied, with 31.2% holding advanced degrees.
The quantitative findings highlight a generally positive attitude among nurses toward continuing education (CNE), with many actively participating in such programs and often funding them personally. The main motivators for participation include benefiting family and friends, maintaining and developing professional skills, advancing career prospects, and financial gains. On the other hand, key deterrents are financial costs, demanding work hours, lack of time, family responsibilities, fatigue, and insufficient financial incentives. Unifactorial analysis and multiple linear regression models reveal the influence of demographic variables on nurses' professional development and well-being, offering insights into the factors shaping their job experiences.
The qualitative research employed semi-structured interviews as the primary data collection tool, allowing for flexibility while maintaining a structured approach. The interview guide, developed by the researcher and validated by professors, consisted of five sections similar to the quantitative questionnaire. The first section gathered demographic data, while the second explored participants' attitudes toward continuing nursing education (CNE). The third section focused on motivations for CNE participation, and the fourth examined barriers. The final section addressed funding sources for CNE, highlighting a common issue where healthcare providers often place financial and logistical burdens on nurses, despite advocating for a skilled workforce.
The qualitative research revealed that most participants have positive attitudes toward continuing nursing education (CNE) and actively engage in such programs to stay updated and acquire new skills, enhancing patient safety. A key finding was the preference for online CNE programs, attributed to their convenience and flexibility, allowing nurses to participate from any location at any time. This suggests that online formats are more appealing and accessible for nurses balancing demanding work schedules with professional development needs.
