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Factors influencing continuing
professional development
A Delphi study among nursing experts
Gerard Brekelmans
Department of Research and Education, Erasmus MC, Rotterdam,
The Netherlands
Rob F. Poell
Department of Human Resource Studies, Tilburg University, Tilburg,
The Netherlands, and
Kees van Wijk
HRM and Healthcare Research Group, Erasmus University, Rotterdam,
The Netherlands
Abstract
Purpose – The aim of this paper is to present an inventory of expert opinions on the factors that
influence the participation of registered nurses in continuing professional development (CPD)
activities.
Design/methodology/approach – A Delphi study was conducted among 38 Dutch experts
(nursing employers, managers, education institutions, and professional associations). Data collection
comprised three rounds: experts completed two consecutive rounds of questionnaires and participated
in a discussion meeting.
Findings – Main influencing factors were: a CPD registration system, the attractiveness of the
nursing profession, nurses’ identification with the nursing profession, opportunities for workplace
learning, the line manager as role model, and attractive education programs.
Research limitations/implications – Being part of a larger study, for the present paper only
nursing experts were asked their opinion about shaping CPD for nurses. Further research should bring
in the views of nurses themselves and investigate how the wider environment influences CPD
participation.
Practical implications – As all stakeholders were found to have their own roles in the CPD process,
collaboration among employers, managers, education institutions, and professional associations will
be crucial to create a conducive learning climate for nurses. HRD practitioners in healthcare can use
the study findings to advise hospitals about implementing the right conditions to support CPD for
nurses.
Originality/value – A qualitative study using the Delphi method to discover factors influencing
CPD in nursing had not been conducted before. Unlike many studies looking essentially at formal
education, the present paper takes into account workplace learning among nurses as well.
Keywords Continuing professional development, Delphi study, Nurses, The Netherlands
Paper type Research paper
In nursing literature the terms continuing professional development (CPD) and
continuing professional education (CPE) are often used interchangeably (Perry, 1995).
While CPE is more focused on didactic principles and formal educational contexts,
CPD is more focused on self-directed learning, in which the nurse is the director of his
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/2046-9012.htm
Factors
influencing CPD
313
Received 16 March 2012
Revised 3 August 2012
Accepted 10 December 2012
European Journal of Training and
Development
Vol. 37 No. 3, 2013
pp. 313-325
qEmerald Group Publishing Limited
2046-9012
DOI 10.1108/03090591311312769
or her own professional development (Grant and Stanton, 1998). CPE forms a
significant element of CPD (Murphy et al., 2006) because tailor-made education
programs are important to develop the right skills as a professional. In the present
study we use the term CPD unless referring to or citing from specific literature where a
different term is used. The American Nurses Association (ANA) describes CPD as:
[...] a lifelong process of active participation by nurses in learning activities that assist in
developing and maintaining their continuing competence, enhance their professional practice,
and support achievement of their career goals (ANA, 2000).
The Royal College of Nursing in the UK describes CPD as:
[...] fundamental to the development of all health and social care practitioners, and (...) the
mechanism through which high quality patient and client care is identified, maintained and
developed (Royal College of Nursing, 2007, p. 2).
The difference between these two descriptions is that the first one also includes career
goals, which is a more personal motive.
CPD plays an important role also in maintaining and improving the quality and
efficiency of the healthcare system (Cooper, 2009). CPD is essential for nurses to enable
them to provide safe and effective care; additionally, it improves job satisfaction and
decreases burnout (Department of Health, 2003; Gould et al., 2006, van Wijk, 2007).
Healthcare organizations need to demonstrate that their members are accountable,
efficient, and effective. Employers want staff with appropriate skills and knowledge to
deliver excellent care (O’Sullivan, 2004). It is therefore essential that employers create
conditions for nurses that encourage them to take part in CPD activities (Hallin and
Danielson, 2007). Speet and Francke (2004) indicate that more studies are necessary to
identify what kind of individual professionalization support nurses need in addition to
their initial education.
Nurses participate in CPD for many reasons. In an earlier Dutch study, Speet and
Francke (2004) showed that nurses deem CPD important. Working together, reflection
and evaluation of daily practice, and working within legal requirements were
mentioned by nurses as the most important reasons for participating in CPD activities.
The least interest was given to “acting on the basis of theoretical notions”, “using
(nursing) scientific research” and “making a contribution to professionalization of the
nurse profession”. In countries such as the USA and the UK, nurses must demonstrate
that they meet the established requirements for renewing their registration (Edmunds,
2007; Gallagher, 2006). In other countries, such as Australia, nurses have a professional
responsibility through codes of professional conduct to remain competent (Gallagher,
2006).
Under the influence of changes in healthcare in The Netherlands (technology and
increasingly complex treatments) the nursing profession has changed over the last
decades. The profession became recognized by law with the passing of the BIG Act (on
professions in individual healthcare) in 1993. It has its own knowledge domain (Leistra
et al., 1999) and education is institutionalized (Ministries of Education, Culture and
Science, and Health, Well-Being and Sports, 1996). As in other countries, Dutch nurses
must demonstrate that they remain competent since the passing of the BIG Act. Also
the practice of nursing care has become more evidence based and less based on
historical findings or trial and error. These all are features that a profession must have
to distinguish themselves from other occupations (Freidson, 2001).
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The need to keep “up to date” professionally to ensure high quality of care has
become of critical importance. CPD is a necessity to deliver safe and effective health
care (Gould et al., 2006). As Speet and Francke (2004) pointed out, there is a difference
between nurses that carry out their operations routinely and nurses that have a clear
vision about the nature and the importance of their profession and about their own
professional tasks and responsibilities. This last group uses current knowledge and
insights that have been developed by the profession itself. They reflect on their roles,
responsibilities, and motivation related to nursing and patient care.
In summary, the importance of CPD is widely supported (Flanagan et al., 2000; van
der Krogt, 2007). Whether or not nurses actually participate in CPD can be influenced
by several factors, which will be outlined below.
Influencing factors
According to Johnson et al. (2011), investment in learning and development for nurses
has a positive impact on patient care, the individual nurse, and healthcare
organizations. At the individual level, the key factors appear to be awareness and
understanding of CPD, conflicting demands on time, the availability of funding, and
access to CPD resources (Hemmington, 2000). However, the individual motivation of
the nurse to engage in CPD is fundamental (Ellis and Nolan, 2005; Hughes, 2005).
Individual motivation is among the most significant factors identified as contributing
to participation in CPD (Furze and Pearcey, 1999; Nolan et al., 1995).If the nurse is not
motivated to change his or her behavior, no amount of CPD (whether mandatory or
voluntary) will be effective (Gallagher, 2006). Professional development should be a
belief (Lannon, 2007), which each nurse must take personal responsibility for.
Impeding factors include the amount of time needed to commute to study venues, child
care issues, and problems accessing facilities after working hours. The most critical
factor, according to the nurses themselves, is the amount of private time that needs to
be invested in CPD activities (Gibson, 1998; Gould et al., 2006). The demands of
undertaking CPD conflict with domestic commitments, which is perceived as a barrier
to achieving a desirable work-life balance (Grossman, 1998; Lawton and Wimpenny,
2003).
At the level of the organization, the role of CPD is affected by its relationship to
organizational strategy, the commitment of key decision makers, and the provision of
an internal infrastructure for CPD. Without the support and encouragement of their
employer, nurses will experience difficulties in their professional development. The
overwhelming majority of nurses need support and advice for CPD (Hemmington,
2000; Murphy et al., 2006). A non-inclusive style of nursing management and lack of
support from managers have been identified as barriers (Nolan et al., 1995). Another
study showed that in a hierarchical organization with little support from colleagues,
employees did not often practice any new ideas in their work (Daley, 2001).
Various other factors also affect both the individual’s and the organization’s
commitment to CPD and ability to implement CPD, including professional
development planning, learning culture, and the dynamics of change (Hemmington,
2000). Professional development can take many forms; however, fostering an
organizational climate in which development is integrated into everyday working
practices was felt to be just as valuable in one study (Gibson, 1998). Nurses require a
stimulating work environment, in which coaching and support to engage in CPD are
Factors
influencing CPD
315
key components (Danielson and Berntsson, 2007). Teamwork and team spirit, the
attitudes of the nurses themselves, possibilities to participate in training programs, and
effective communication all stimulate CPD. High workload, lack of available literature
at the workplace, and inefficient communication with the management are obstructing
factors (Speet and Francke, 2004).
A number of parties are involved in shaping and delivering CPD activities for
nurses. Employers and managers are involved by creating the right conditions (time,
money, learning environment), professional associations by indicating which
standards of the profession must be met, and institutions by offering appropriate
educational programs. Furthermore, professional associations can support nurses and
healthcare organizations by giving them information about the issue of how
professional development can be stimulated (Speet and Francke, 2004). These parties
therefore all have different roles regarding CPD for nurses.
As the literature review shows, many factors influencing CPD have been put
forward in literature; however, what is not clear as yet is what are the most important
factors influencing nurses’ participation in CPD. The aim of this study is to identify
and prioritize, according to nursing experts, the factors that influence the participation
of nurses in CPD activities.
Method
Research design
To identify and prioritize the factors influencing nurses’ participation in CPD activities,
a Delphi study (Brockhoff, 2002; McKenna, 1994) was carried out among a panel of 38
experts (Table I). The following definition of an expert was used: “one who has skill,
experience, or extensive knowledge in his calling or in any special branch of learning”
(Webster’s Online Dictionary, n.d.). Data collection in this study consisted of three
Area of nursing n
Professional Associations 9
Dutch nurses 1
Emergency room nurses 1
Intensive care nurses 2
Obstetric and gynecology nurses 1
Oncology nurses 2
Nurses in childcare 2
Educational institutions 5
Association of Education Centers in Healthcare 4
Dutch Association of Educators 1
Management 23
University hospital 7
General hospital 6
Regional hospital 10
Employers 1
National Federation of University Hospitals 1
Note: N¼38
Table I.
Participants in the Delphi
study
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rounds.The first two rounds consisted of written questionnaires (see Appendix) and
the third round comprised a face-to-face discussion among the panel.
Sample
Participants were selected for their nursing backgrounds in combination with their
current jobs. They all had extensive domain knowledge. Representatives of
professional organizations (chairmen), employers (policy officers and managers), and
nursing education (educators and head of the department) were approached (N¼46).
Ultimately, 38 individuals agreed to participate. Table I describes the sample. Consent
to participate was given by the boards of their organizations.
Instruments
The data collection tools utilized for this study were largely based on previous research
carried out by Gibson (1998). The three-round method promulgated by Gibson (1998)
was also used in the present study with the exception of the third round, where a
discussion meeting was used. The reason to hold this meeting rather than have yet
another questionnaire (as Gibson did) is that discussion and debate were deemed to
have a greater added value to the present study. In this way, common issues can be
examined more thoroughly, depending of course on the number of actively
participating experts (Brockhoff, 2002).
Procedure and analysis
In the first Delphi round, the members of the expert panel received a questionnaire
containing nine open-ended questions (see Appendix). Their answers from the first
round were summarized in mind maps by the first author. For each participant
background (nurse associations, nursing educators, managers, and employers) a
separate mind map was created. In the second round, the participants received a
follow-up questionnaire (see Appendix) containing seven questions based on the
summary from the first round. Answers from the second round were summarized in
mind maps as well.
As a next step, content analysis of the data gathered in the first two rounds was
carried out by the first author. In the third round, a face-to-face discussion meeting was
organized among the experts based on this content analysis. The aim of the discussion
was to validate the findings from the first two rounds by reaching consensus about
which main factors influence nurses’ participation in CPD. Additionally, a number of
suggestions were put forward about the shaping of CPD and about the specific roles
that the various stakeholders should play in supporting CPD for nurses.
Results
The results demonstrated a clear consensus among the experts on the need for nurses
to participate in CPD activities. The different stakeholders did seem to hold different
viewpoints on the definition of CPD. However, there was common ground in a focus on
the responsibility and desire to deliver high-quality patient care. Consensus was
ultimately reached on the following definition of CPD:
CPD means systematically and deliberately developing one’s professional repertoire aimed at
improving one’s performance as a professional and one’s quality of care as a nurse, member
of the team, and of the organization, to the highest possible level.
Factors
influencing CPD
317
Ultimately, CPD should affect the quality of care provided to clients by the nurses. In
the opinion of the panel, the need for CPD is also located in the identity of the nursing
profession. Inquisitive/analytical ability, initiative, flexibility, and critically reflective
work behavior were the most important characteristics of the nurse profession
mentioned by the experts. Furthermore, nurses have to be able to provide
patient-centered care, work independently, and collaborate with other disciplines. As
a member of a multidisciplinary team it is necessary to have a recognizable
professional identity. In this way CPD is also important from a professional interest
(development of the nursing profession).
Influencing factors
The results from the questionnaires and face-to-face discussion meeting demonstrated
a clear consensus by the experts on the need for nurses to participate in CPD activities.
There were six main factors that were deemed to influence participation, which will be
illustrated below.
(1) CPD registration system:
Find a balance in attractive and compulsory education (Educator; School of Nursing,
female 53 years)
Encouragement and support were mentioned by line managers and educational
institutions as playing a pivotal role. Nurse associations advocated a more
mandatory way to encourage CPD, that is, the implementation by the Dutch
NursingAssociation of a national CPD registration system with a minimum
number of mandatory training credits each year. Currently, the Netherlands
does not have such a system.
(2) Attractiveness of the nursing profession:
There is a need for CPD because nursing is a profession and not a vocation. The
ongoing changes within healthcare scream for development (Employer; National
Federation of University Hospitals, female 50 years).
CPD also has a more commercial/human resource interest for retaining staff.
This is important in times of shortages and, during the discussion, the following
question was raised; what would affect the attractiveness of the nurse
profession? Decreasing workload and increasing finance and opportunities for
learning and personal development were mentioned. The most important
recommendation to the employers was to create a strategic policy for CPD with
good conditions and facilities to support this. Creating conditions to integrate
nursing science in daily practice was mentioned as well.
(3) Identification with the nursing profession:
We can see the consequences of what we have neglected for a long time; it is too
simple to now point to a lack of responsibility among the nurses (Nurse Manager;
General Hospital, female 52 years).
Mentality among nurses came up as an important factor. There was clear
consensus advocating a change of mentality among nurses, from apathy to
assuming responsibility for their own professional development. There was
some support for the premise that most nurses do not undertake CPD activities
by themselves. It was felt that the need for CPD is still not sufficiently
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recognized by nurses. Ageing was considered an important obstacle in CPD
participation. The average age of nurses is increasing and as a result their
motivation to invest in personal development is decreasing. The panel of
experts also mentioned that nurses are by definition caretakers and less focused
on themselves and their own situation. This personal characteristic seems to be
ingrained in the nursing profession. A recommendation by the panel was to
encourage nurses to take more responsibility in taking part in CPD activities
and clearly indicate what support they need, explore the opportunities at the
workplace, and use different ways of learning to support CPD (e.g. reflection,
3608feedback, and peer assessment). Most of all, nurses should be proud to be a
nurse and show what they do and how they do it (professional standards and
registration).
(4) Opportunities for workplace learning:
Every nurse learns informally continually, so explicit informal learning (Educator;
School of Nursing, male 45 years).
A lack of financial resources for participation in training programs, a heavy
workload, lack of time for CPD activities, and staff shortages were mentioned as
contextual barriers. Also often mentioned were cultural aspects and
communication between the staff and other disciplines. The experts
wholeheartedly agreed on the need to create the right conditions for workplace
learning, for example, opportunities to engage in case discussions, reflection,
action learning, dialogue and peer feedback. Instruments such as portfolios and
personal development / activity plans can also encourage participation in CPD.
(5) The line manager as role model:
The leader sees and recognizes the talents of individuals and looks together with the
person for learning and development opportunities that add value for both individual
nurses and the department, division, or organization (Employer; National
Federationof University Hospitals, female 53 years).
According to the panel, line managers need to acknowledge the tangible
outcomes of professional development and reward them. Managers need to
avoid, however, exercising control over the process of CPD. Nurse autonomy
should be encouraged when it comes to professional development. The manager
as a role model, engaged in his or her own developmental process, ensures that a
good training policy and appropriate facilities are in place. Managers
displaying leadership with a clear vision, creating appropriate structural and
cultural conditions for CPD, would enhance the effectiveness of CPD. Lack of
attention, lack of appreciation, and a perception of not being heard by their
managers are cases in point. Conservative leadership and a lack of
implementation of policies (“paper tigers”) were mentioned in passing. The
recommendation to the managers and nurse leaders was to give more autonomy
to the nurse and to develop expertise on the ward but most of all show
leadership and be a role model to their staff.
(6) Attractive education programs:
People are willing to develop, as long as it is attractive (President of the Nurse
Association, female 53 years).
Factors
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319
Experts agreed that education centers could encourage CPD by offering
demand-oriented as well as supply-driven training courses. It was, however,
deemed important to make (especially compulsory) education programs more
attractive and accessible to nurses.
Workplace learning is the keyword so nursing educators should take advantage of the
expertise on the wards, be a consultant regarding learning strategies, provide
challenging and accessible additional learning programs, and use the available digital
opportunities.
Conclusions and implications
This study aimed to identify and prioritize factors for registered nurses to participate
in CPD activities. A three-round Delphi study was conducted, involving 38 experts
representing nursing associations, nursing education, nursing management, and
nursing employers.
There was a clear consensus on the need for participation in CPD activities as it
affects the quality of care provided by nurses to clients. Important roles were identified
for education providers, staff, and other stakeholders (the organization and line
managers). This result is consistent with the study by Danielson and Berntsson (2007).
According to the experts, however, furthering awareness and a change of attitude
towards CPD among nurses will be necessary. This supports the view expressed by
Nolan et al. (1995), that one of the most significant factors identified is individual
motivation. On the other hand, according to Hemmington (2000), an overwhelming
majority of nurses need support and advice for them to increase their participation in
CPD.
A CPD registration system, the attractiveness of the nursing profession, nurses’
identification with the nursing profession, opportunities for workplace learning, the
line manager as role model, and attractive education programs were mentioned as
main motivating factors. The Institute of Medicine (2009) described a CPD registration
system as “a coordinated continuing professional development system”. Factors to
increase the attractiveness of the profession included financial resources, workload,
time and decreasing staff shortages. Factors related to the identification with the
nursing profession included nurses’ age and propensity to care for others rather than
for themselves. These factors correspond to what has been described in previous
literature (Gibson, 1998; Gould et al., 2006).
Recommendations made to the managers and nurse leaders in the discussion round
were to give more autonomy to the nurse and create a strategic policy for CPD. This
must, however, be in line with the wider policy within the organization. McCabe and
Garavan (2008) described “the fault line” between nurses and the organization by
introducing general management concepts and practices. This “fault line” is caused by
managers not using language that is commonly understood by nurses. In this way,
organization development can lead to loss of commitment among nurses.
The suggestion that the HRD department in hospitals has an important role by
devising HRD initiatives is clear but strongly depends on the position of HRD in the
organization. It is evident that the HRD department does not always have the position
it needs to fulfill this role. In The Netherlands, this position ranges from a close
collaboration with the Human Resource Management function to a mere provider of
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training programs. A clear view about the results and effects of HRD activities is
necessary at a time when economics and financial outcomes are becoming more and
more important. A key challenge for HRD in the coming years will be to make this gap
smaller and strengthen its position in healthcare.
A number of limitations of this study need to be mentioned. First, data collection
was time consuming due to the use of three sequential rounds, which may have
affected the response rate. In terms of methods used, however, the Delphi technique
was found to be very useful to identify a wide range of issues that have an impact on
nurses’ CPD participation. This would have been difficult to achieve using a survey.
Second, the opinion of a panel of experts was heard and not the opinion of nurses that
work at the bedside. To avoid bias (socially desirable answers) nurses were not asked
for their opinions in the present Delphi study. Further research should be done into
their perceptions of the process and results of CPD, in order to get a full picture about
the subject. The most important factors mentioned in this study are related to the
nurses themselves; therefore their voices must be heard as well.
Further research
The importance of CPD is clearly supported in literature and in the present study
(Flanagan et al., 2000; Speet and Francke, 2004; van der Krogt, 2007). What is as yet
unknown, however, is how nurses themselves understand the process of CPD
(Barriball et al., 1992; Nolan et al., 1995). This understanding is essential if nurses are to
be responsible for their own CPD (Griscti and Jacono, 2005).
Several factors can influence the process of CPD in a positive or negative way, as the
present study has shown. Further research among a generalizable sample of nurses
will be needed to corroborate the findings, as indicated above. Another question that
remains open as yet is in what way the wider environment influences CPD activities.
The complexity and variability of the environment could have an effect on the
available learning opportunities as well. What influence do these (often) informal
learning moments have on CPD of nurses? The powerful influence of the learning
environment has been described extensively in literature (Keeris, 2006; Heikkila and
Makinen, 2001). This is reflected, for instance, in the way in which formal learning
paths are currently constructed (competence oriented) and established within various
regulatory systems. The environment can also, however, be characterized by factors
such as production and personnel shortages. In what way are these factors barriers to
creating a stimulating learning culture and does this lead to a greater recourse to
individual responsibility, autonomy, and self-directed learning? Further research will
need to shed more light on these questions.
Implications for HRD Practice
Nurses are responsible for identifying their own professional development needs. This
topic is explored in the learning-network theory (van der Krogt, 2007). The basis of the
learning-network theory is that various actors shape networks, namely, work (care),
the HRM process (personnel flow) and the HRD process (learning). These actors
(nurses, managers, HR staff, etcetera) are the engines of the organization; they create
these three processes and by doing this also shape their professional development.
Nurses participate in these processes as well and gain experiences that can be relevant
to their professional development. How nurses go about creating new experiences is
Factors
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321
crucial for their professional development. Nursing educators can help them give
meaning to their efforts in this area.
In line with the learning-network theory, all stakeholders were found in the present
study to have their own specific roles in supporting and facilitating CPD for nurses.
Study by Jordan (2000) have demonstrated a clear link between CPD for health care
professionals and clinical outcomes for patients. In conclusion, collaboration among
the different stakeholders seems crucial to create a climate in which nurses are able to
participate in CPD activities and learn autonomously. It will be up to HRD
professionals to create opportunities to build bridges between the different actors and
jointly seek solutions leading to improved professional development of nurses.
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Appendix
Questionnaire used in Round 1
(1) “Life long learning”; what does this mean to you?
(2) “Continuous professional development”; what does this mean to you?
(3) What are the characteristics that a good professional nurse must have in relation to
creating her/his professional development?
(4) Which motivating factors for participation in CPD are present in your opinion?
(5) Which conditions for participation in CPD should be present?
(6) Which impeding factors play an important role in CPD participation?
(7) In what way should CPD be shaped?
(8) In what way can the nursing profession become more attractive?
(9) An important aspect in shaping CPD is the environment in which it takes place. What
conditions would the workplace of nurses have to meet?
Questionnaire used in Round 2
(1) The responses from the first questionnaire on the need for continuous professional
development (CPD) for nurses were not entirely clear to us. Do you see the need for CPD
and, if yes, what does it look like?
EJTD
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(2) The concepts of learning and development were mentioned a lot in response to the first
questionnaire; however, often seemingly referring to the same notion. What are your
definitions of both concepts and what is, in your opinion, the difference between the two?
(3) CPD for nurses; what is your role, speaking from your current job, in this process?
(4) In answer to various questions, the concept of culture was mentioned a lot; in particular
the notion of a learning climate. What do you understand by the concept of a learning
climate?
(5) The workplace was often mentioned as an important context for CPD to take place. What
is your definition of workplace learning?
(6) Leadership was often mentioned in response to questions about promoting, supporting
and impeding factors for CPD. Which features of leadership are needed to enable CPD for
nurses?
(7) What is your view regarding compulsory training activities serving registration
systems? Please motivate your answer.
Corresponding author
Gerard Brekelmans can be contacted at: g.brekelmans@erasmusmc.nl
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