PERCEPTION OF REGISTERED NURSES ON IMPLEMENTATION OF MANDATORY CONTINUING PROFESSIONAL EDUCATION FOR RE-LICENSURE IN PEDIATRIC INSTITUTE Devi A/P KsSaravana

Muthu Pediatric Hospital ,Kuala Lumpur Chong Mei Chan Monash University
Awareness to mandate continuing education for registered nurses fro re-licensure began in early 1970s in developed countries like America and Great Britain. However, it is believe that MRCP would improve the quality of nursing practice. However, it remained as controversial issues. In realizing the importance of mandatory to nursing practice, the Malaysia, continuing professional education (CPE) is still considered as voluntary, although it is stated in code of professional conduct for nurses that nurses are supposed to obtain minima of 10 hours CPE points annually. The purpose of this study is to explore the nurses perception towards mandatory continuing professional education (MCPM). This is a cross sectional descriptive study which was done in the clinical areas in Pediatric Institute, Kuala Lumpur Hospital. 50 %( n =200) of the total RNs in the clinical areas in Pediatric Institute were selected randomly for the study. Self explanatory questionnaires were used to collect the data. The data was analyzed using SPSS version 11.5. The finding found that high perception on CPE and moderate agreement on MCPE for relicensure. The finding reveal RNs have a positive attitude towards MCPE. It is suggests that a personal factor does significantly influence the participation. Chi-square test was used top test the relationships and showed a significant relationships, example year of service and education level (P<0.005).In conclusion, MRCP is considered to be an important measure to increase nurses participation in CPE. Therefore it is timely for justifying the introduction of MCPE for re-licensure, by thoroughly investigating the proportion before it is implemented.

Introduction
The phenomenon of continuing professional education (CPE) has been globally recognized by all professionals as a primary method to top up basic professional education regularly. As the 21st century begins, the scientific discoveries, technological advances and increasing demand from the society have influenced the need for continuing education for professionals. So in order to keep practice relevant and future orientated, professionals need to keep updated with current trends and issues so that they dont practice obsolete practices that have been emphasized as ineffectiveness. CPE in health care disciplines is accepted as an essential component of professional practice due to the fact that there is an rapid changes in structure and culture of health care industry(Mersery & Manso, 1987 cited in Hogston 1995). Thus the importance and relevance of CPE to nurses has been increasingly emphasized and repeatedly asserted throughout the literature ((Fruze, 1999; Furze & Pearcey, 1999; Lee & Levet-Jones, 2005; Macdonald, 1994; Thurston, 1992). Further more Mersery & Manso (1997) as cited in Hogston (1995) have reported that in order for nursing profession to achieve professionalism, it require greater skill, higher education and life long learning. This is supported by William (1977) that , knowledge that is acquired through basic professional education has a half-life of about two and a half
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years and b the end of that period, whether knowledge is acquired from their basic professional education will become outmoded or obsolete. This is further supported by Gillies & Petengill (1993) as cited in Beatty(2001) that basic education for practice becomes obsolete within 5 years of graduation and the obsolescence can cause nurses to perform poorly and lead to client disability, continued illness and even death of clients. So it is important that nurses need to update their knowledge and skill continuously (Schoen 1982). In addition, Newman (1986) as cited in Tomey & Alligood(2002) have further reported nursing is at the intersection of the focus of the health care industry, therefore nurses are in a position to bring about the fluctuation within the system to a new, higher order of functioning. Therefore education obtained at a higher level would necessitate a shift in thinking from the existing view of health to a newer and synthesized view that accepts disease as a manifestation of health. Advocates for mandatory CPE (MCPE)state that the reasons to imposed MCPE are to improved nursing practice through increases competency, increases productivity in professional roles, the development of new skills and knowledge and keeping abreast of new developments in nursing (Adami & Kiger, 2005; DeSilets, 1995). Many researchers asserted that most of the nurses do not voluntary update their professional knowledge regularly, thus mandatory requirement is timely to be implemented (Chiarella, 1990; Hibbs, 1989; Kershaw, 1984). This is supported by Adami & Kiger (2005) that MCPE is prerequisite to high standard care delivery and it should be compulsory to ensure who need most will turn up. It is in line with the code of conduct, all registered nurses are required to assume responsibility for continuing education (United Kindom Central Council for Nursing, Midwifery and Health Visiting, 1992). Many studies have argue that MCPE is a prerequisite for re-registration to overcome the problems of laggards, patchy, unplanned provision of CPE and barriers to uptake ((Hogston, 1995; Hutton, 1987). More recently in Australia, a discussion document on continuing professional development (CPD) for registered nurses and midwives in Victoria has been circulated which outlines a proposal to introduce a compulsory continuing professional development program linked to annual registration (nurse Board of Victoria, 2006). In Malaysia, the registered nurses form the largest group of health care personal, providing health care services to the countys population both in the public and private sectors. These nurses undergo three years of Diploma or four years Degree in nursing education and are registered with the Malaysia Nursing Board. In the both program, nurses are introduced the concept of continuing education. Subsequently their participation in CPE activities will largely depend on the influence of nurse educator, nurse manager or peers. In line with the issue, in the Malaysian Nursing Act 1950, there was no clause stipulating the requirement of voluntary or mandatory continuing professional education for the re-licensure of the nurses annual practicing certificate. As such, registered nurses (RNs) in Malaysia have since participated in available CPE activities on their own initiative due to interest in a specific subject. However the globalization wave regarding development in nursing has influenced the Nursing Board of Malaysia in 1998 had included the requirement of continuing education in the Nurses Code of Conduct. All nurses should at least have ten contact hours in CPE activities a year. Since the addition of this statement, nurses participated in available CPE activities on their own initiative and on voluntary basis because the Nursing Board did not mandate the participation. Hence the question arise whether our Nursing Board Leaders, heath authorities, consumers and legislators and the registered nurses themselves should voluntary participation to continue or should it be changed to the mandatory approach to CPE. Nursing Board Malaysia in realizing the important of CPE had proposed guideline of CPE and legislation of MCPE for Malaysia nurses. It has implemented in 2008.

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The legislation of MCPE will be able to ensure each and every member of nursing profession to undertake the responsibilities on themselves to update their knowledge and skills regularly so that the clients interest is always safeguarded. Thus we may see an increase in participation in CPE activities in the future, as is seen in many other countries in the world that have implemented this ruling as criteria in obtaining their nursing practicing license. Unfortunately this assumption cannot be taken into consideration but it must also be seen from the RNs point of view regarding the implementation of MCPE for re-licensure. Therefore agreement and cooperation from all the RNs practicing in Malaysia is required if the Nursing Board of Malaysia wants to implement the MCPE for re-licensure successfully. Study Aim and Objectives The aim of this study is to assess the perception of pediatric nurses regarding implementation of mandatory CPE participation for re-licensure. The objectives of the study: 1. to explore the registered nurses perception towards CPE 2. to determine registered nurses perception towards implementation of mandatory CPE for relicensure. 3. to determine the relationship of demographic characteristics on the perception of registered nurses regarding the implementation of mandatory CPE for re-licensure. Methodology This is a quantitative study using non-experimental with cross-sectional design to examine the registered nurses perception on implementation of mandatory continuing professional education for re-licensure. The study was conducted at the clinical areas in Pediatric Institute, Kuala Lumpur Hospital. The hospital has 415 registered nurses. The nursing staff makes up the major population of personal in the hospital. The registered nurses comprise of basic diploma trained nurses and post basic pediatric, intensive care, oncology, orthopedic, neonatology, and nephrology. Nursing staffs are distributed in various areas of the hospital according to patient care needs. The data was collected using the self explanatory questionnaire technique. The completed survey forms were collected within a time frame of two weeks. The participants were explained briefly regarding the study before the questionnaires was distributed. All participants were instructed to put the completed questionnaires in an envelope and seal it so that to maintain confidentiality. The target population was 415 registered nurses in Pediatric Instituted. A total of 200 samples were selected using stratified random sampling method. According to number if staffs from 16 wards/units in the hospital. The instrument used was modified and adapted from previous literature (Larocco & Polit, 1978). A total of 21 items of self- reporting questionnaire was used in this study. A 5- point likert scale was used to indicate relative agreement for each item. Response choices range from 1 (strongly agree) to 5 (strongly disagree). The questionnaires are divided into 3 sections which consists of: section A consist of demographic data of the respondents; section B of the questionnaire asking the perception of registered nurses regarding continuing professional education and finally section C consist of questions to explore nurses perception regarding mandatory continuing professional education.

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Validity & reliability of the questionnaire was determined by consulting the experts and pilot study was conducted to pretest the tool. A Crobachs Alpha Coefficient of .597 and .671 illustrated an acceptable degree internal reliability related to the key variable of research use in practice. Ethical consideration was obtained from the Director of Kuala Lumpur and Assistant Director (Medical) of Kuala Lumpur Hospital. Informed consent was implied by return of the completed questionnaire in the sealed envelop. Data was analyzed using the SPSS statistical Package version 11.5. Frequency, percentage, means and tables were used to describe the data. Cross-tabulation with Pearson Chi-square test was used to identify the relationships between relevant variable. A p value of < 0.05 was used to establish statistical significance.

Finding and Discussion

The total respondent in this study are 200 RNs from various wards and units in Pediatric Institute, Kuala Lumpur Hospital. The total population was 415 and only 50% of the population was involved in the study. The response rate was 96.6. Table one shows demographic data of this study. Majority of the respondents are junior nurses and are below the age of 35 years old which belong to the reproductive age group. This is primarily because the turnover of nurses in Kuala Lumpur Hospital is great. Only ten percent of the nurses have post basic or tertiary qualification, because the study setting is a tertiary centre and situated in the capital of Malaysia thus it becomes a transit centre for nurses whereby they usually get transferred to their native village or follow their spouse. In this study, the participation of respondents in CPE program was quite encouraging only twelve percent have not attended any form of CPE activities for last two years due to the fact that they have just qualified and still in the transition period of getting adjusted to working life. The educational method with most participation was in-service followed by seminar, workshop and finally conference the finding is congruent with study by Harpes(2000). This phenomenon is probably due to the fact; the CPE are offered weekly in the Institute and enable the nurses to attend freely. Secondly, their participation is in full force because CPE attendance is made compulsory and this is used as criteria for annual pay revision assessment. Although many adult learning theorists have said that learning cannot be forced but the enforcement in way or rather have increased nurses participation in CPE activities. Only 45% of the respondents have indicated that they have read one or more nursing journals in the past two years and only 29% of the nurses assess internet for CPE purpose. This finding reveals that the respondents are not aware, or not interested in information seeking pertaining to nursing using the latest trends in information technology. The potential explanation of the above ma be because of lack of facility such as computer for assessing internet and also lack of nursing journal I the small library in pediatric Institute. These study are congruent with study finding of Wan(2002) where the study finding reveled nurses have less interest I reading habits.

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Table 1: Demographic Characteristic of Respondents (N=200) Percentage Demographic Data Frequency Age 25 26-35 36-45 46 Highest Professional Education Certificated/Diploma Post basic/ Degree Attendance to CPE in last two years seminar conference In-service education Journal read in past 2 years Assess internet 69 88 13 30 180 20
176 80 35 180 90 59

34.5 44 6.5 15 90 10 88 40 17.5 90 45 29.5

Respondents in this study have favorable attitude towards CPE, as shows in the table 2 most of the respondent agree that CPE is valuable for nurses professional practice, CPE is necessary for better patient care , rapid technological changes make it necessary for nurses to upgrade their skills through CPE and participation in CPE activities contributes to increase in professionalism. This could be interpreted an indication that nurses are aware of the need to be knowledgeable of the changing techniques and concepts n their profession. Nurses acknowledge and support the practice of CPE in their nursing profession and perceive attitude towards it (Kersatism 1997: Hogston, 1995: Harpes, 2000). Most of the respondent disagree that the CPE activities are not required for experience nurses, this has showed that nurses understand the needs of life long learning. As whole the respondents have positive perception over CPE for nurses.

Table 2: Distribution of respondents regarding statements on perception of CPE (N=200)

Statements Participation in CPE is valuable for nurses professional practice Participation in CPE is necessary for better patients care Rapid technological changes make it necessary for a nurse to upgrade her skill through CPE Participation in CPE activities contributes to increase in professionalism Hospital should have more CPE programs available for nurses CPE activities is not required for those nurses who are experienced Strongly Agree n (%) 100(50) 100(50) 108(54) 105(52.5) 117(58.5) 0 Agree n (%) 80(40) 80(40) 70(35) 60(30) 50(25) 13(6.5)
uncertain Disagree Strongly Disagree

n (%) 19(9.5) 19(9.5) 21(10.5) 34(17) 32(16) 29(14.5)

n (%) 1(0.5) 1(0.5) 1(0.5) 1(0.5) 1(0.5) 108(54)

n (%) 0 0 0 0 0 50(25)

Table 3 shows the perception of respondents of MCPE that only one quarter of them agrees MCPE should be require for licensure and 40% do not committed them. Perhaps nurses who genuinely favour MCPE feel that colleagues do not hold their views. On the other hand, nurses who do not favour MCPE feel that is socially unacceptable. To hold those views so they respond in a more acceptable manner. Some nurses also may feel at ease indicating unsure. (Larocco& polit, 1978). Generally respondent agreed for more
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free programs should be available if MCPE is implemented because nurses comprise of middle-income earners and are keen on free programs due to financial constrains or family commitments. Respondents while uncertain in whether they should be responsible to their learning needs, thus bear the CPE cost their selves. Usually nurses have more positive attitude towards CPE if certain rewards are given for their participation and also employer assistance (Kersaitis, 1997). Younger respondents agree that MCPE requirement will interfere with nurses personal/social life, as they are in the reproductive age , most of them have younger children which has actually cause resistance when MCPE is implemented.

Table 3: Distribution of respondents regarding statements on perception of MCPE (N=200)

Statements MCPE should be required for re-licensure MCPE will ensure continued competence If MCPE is implemented, free programs should be available to all nurses If MCPE is implemented, nurses should be responsible for their learning needs, thus bear the cost themselves MCPE requirement will interfere with my personal/social life Strongly Agree n (%) 18(9) 43(21.5) 105(52.5) 2(1) 59(29.5) Agree n (%) 50(25) 98(49) 55(27.5) 14(7) 51(25.5)
uncertain Disagree Strongly Disagree

n (%) 80(40) 49(24.5) 34(17) 87(43.5) 52(26)

n (%) 52(26) 10(5) 6(3) 90(45) 38(19)

n (%) 0 0 0 7(3.5) 0

Overall analysis shows that nurses with longer years of experience that is 11-220 years and 20 years and above have different perception compared to the group of nurses with 1-5 years and 610 years of experience. This finding is congruent with the study done by (Larocco& polit, 1978 &
Bariball, 1996) where the study findings reveal that younger and less experienced nurses favour MCPE. One of the reasons stated was that younger nurses are more aware of the need to supplement their basic education with frequent updates. Another possibility is that younger nurses are less sure of their skills and feel a need to give them more confidence. Older nurse have been reported to be more of independent learners, thus proffer on the job experiences. Older nurses are also reported to be selective in learning preference while younger nurses have been reported to be more open to CPE programs and not question its relevance. The result of Chi-square analysis failed to find any significant relationship between educational level and perception on CPE in this study. The study finding is also unable to find the significance relationship because of the small number 20 of respondents who have post basic or degree courses compared to the non post basic holders. This study finding is contrasting to the study findings of Lorocco & polit (1978), where it stated that there is a significant relationship between nurses who have received post basic courses and their perception towards CPE because of the education encounter or exposure that they go through during the course. Overall the study findings reveal that there is an association between demographic factors such as age, number of children below five years old and also the years of experience to the perception of RNs regarding implementation of MCPE for re-licensure.

Implication to Nursing
The finding of this study has shown that generally nurse have a positive perception towards CPE and MCPE for re-licensure. DPE is considered and important issue in any profession because it can enhance the growth of the profession thus aids in achieving professionalization in some profession especially nursing profession in Malaysia. This implication has cause the Malaysia Nursing Board to derive a guild line on continuing professional development for Malaysia nurses. CPE has made compulsory for all
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nurses to renew their clinical practice the legislation is mandate and effective from 2008. All nurses are required to attend at least 35 hours of CPE per year in order to renew their license of practice. An out line in the CPD Credit Points System has shown difference activities are awarded difference points. Highest points (50 points) are given to tertiary education such as degree, master and PhD study yearly through out the course. This is step taken to encourage nurses to pursue higher education. The Ministry of Health Malaysia has acknowledged nurses with higher degree in promotion exercise. Thus this external factor has motivated nurses to enroll for higher degree study. The nurse leaders should be a role model to be actively involved in CPE. Predominantly nursing administrative departments should plan and focus more on CPE activities for nurses and ensure that all inservice trading activities are run regular and updated. Plan schedule for their nurses to pursue higher degree education. Provide an environment conducive for nurses to learn for example library facilities and subscribe relevant journals. This study will also give implication to nursing education such as evaluation of the CPE program and the effects of the program nursing education should work together with nursing administrations to reevaluate the CPE program and the adequacy and the quality of the program. In order to upgrade the nursing status in Malaysia, nurses are encouraged to pursue higher education. The nursing education in Malaysia is developing progressively. The degree program was started in 1993 by University of Malaya. It has increases to seven public universities offering full time degree program. There are also distance learning offered by Open University Malaysia, Marsha College University and UITM. The distance learning is using the hybrid on-line learning systems which incorporate the on-line and face-to-face method in delivery of the courses. The distance learning has enabled more nurses to participate in CPE. The degree nursing programs offered are categories in to pre-registrations and post registration cause. Pre-registration course is full time courses usually are for school leaver. However, post registration courses are meant for existing nurses who are desired to pursue tertiary education to upgrade them selves. The nursing degree curriculum in Malaysia generally encompasses nursing sciences, behavioral science, health sciences and information technology and communication skills. Research is an important component of degree program, student are required to attend 3 credit hours of research and biostatic courses and to conduct a project with contribute 6 credit hours of the courses. Generally most of the course offer shared quite similar learning outcome: 1. Acquire current knowledge related to nursing specializations. 2. Demonstrate safe, competent and current skills in related nursing specializations. 3. Demonstrate caring and appropriate attitudes towards clients. 4. Participate proactively, ethically and collaboratively in the health care team. 5. Communicate effectively with internal and external clients. 6. Apply critical thinking and problem solving in the health care team. 7. Communicate effectively with internal and external clients. 8. Demonstrate leadership, managerial, information technology and entrepreneur. 9. Appreciate life long learning to maintain the highest standard of nursing practice. Beside pursue degree program, more nurses are further their study to master and PhD study. Majority of them are self sponsored and doing on their own time. Recommendation

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The study finding reveal that there are certain constrains among nurses in CPE participation. Based on the findings, a few suggestions have been recommended. A more structured program of CPE should be planed and produced with the collaboration of the three aspect of nursing. A nursing committee should plan a structured program where the evaluation of CPE program can be done. With the findings, future activities can be planned accordingly to the learning needs of nurses. A care full planning of CPE program is needed if mandatory CPE has to be implemented. The rationale based upon the factual evidence should be thoroughly examined. Without careful planning and research, mandatory CPE is unlikely to deliver the anticipated development of reflective practice and critical thinking considered crucial for improved patient care. A nursing research team should be formed. All the nursing edge graduates should be motivated to be involved and share their knowledge in doing the research. Research is very important to enable nurses to tackle the issues in nursing profession. The research also can give us guide to implement necessary measures to encounter CPE implementation. In this information communication technology (ICT) era, many young nurses are ICT booming generation; perhaps the nursing administration and education should take advantage of the ICT to promote CPE. Support more tertiary nursing education through on-line learning. Initiate more innovative teaching and learning method such as wetblog, on-line PBL, reflective community and accessibility of e-library. Conclusion From this study finding, it shows that most nurses in institute Pediatric acknowledged the importance and the value of continuing professional education. There are also agreed if the mandatory continuing should be implemented in the organization. Nursing administrative and nursing education should deeply analyze the need to their nurses with regard the mandatory continuing professional education. With the finding s stated above, it is important for the organization and its members to examine the importance and the necessity of CPE and MCPE in our Malaysian setting especially in the Hospital Kuala Lumpur whereby it has about 2000 nurses working here. Collaboration among the nursing leaders in evry area is vital as to increases our practice and the most important, our nursing profession.

References
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Hogston, R. (1995). Nurses' perceptions of the impact of continuing professional education on the quality of nursing care. Journal of Advance Nursing, 22, 586-593. Hutton, C. A. (1987). Impact of mandatory continuing education : A review of research on nurses's attitudes and perceived outcomes. The Journal of Continuing Education in Nursing, 18(6), 209-213. Kershaw, B. (1984). License to practice. Nursing Times, 6, 46-47. Larocco, S., & Polit, D. F. (1978). A study on nursesAttitude Toward Mandatory Continuing Education for Relicensure. The Journal of Continuing Education in Nurisng, 9(1), 25-35. Lee, Y. C., & Levet-Jones, T. L. (2005). Continuing education for nurses: A necessity of a nicety? The Journal of Continuing Education in Nursing, 36, 5. Macdonald, S. (1994). Continuing education- A choice between affluence and deprivation. Morden Midwife, 4(4), 16-19. Schoen , E. C. (1982). Continuing education and the professional orientation of nurses. Research in Nursing and Health, 5, 183-189. Thurston, H. (1992). Mandatory continuing education: what the research tells us The Journal of Continuing Education in Nursing, 23(1), 6-14. Tomey, A. M., & Alligood, M. R. (2002). Nursing theorists and their work. USA: Mosby Inc.

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