Investigation and Analysis of Continuing Nursing Education Status and Needs of In-Service Nurses in Tibet

Objective: To investigate and analyze the current status of continuing nursing education (CNE) of in-service nurses in Tibet and their demand for continuing education. Methods: 663 active nurses in Tibet were taken as the research objects, and the self-developed questionnaire was used to investigate the current status and needs of CNE, and the correlation between the CNE needs of active nurses and their personal conditions was analyzed. Results: This study shows that 65.61% (435/663) of active nurses have not participated in any CNE, and 91.86% (609/663) of active nurses believe that they need to participate in CNE. The problems faced by active nurses in participating in CNE include funding restrictions, time limitation and ability limitation. Logistic stepwise regression analysis reveals that the age of active nurses and working years of nurses are negatively correlated with the funding restrictions for participating in CNE (P < 0.05). It is relatively more difficult for young nurses with less working experience to obtain funding for participating in CNE. Moreover, there is a negative correlation between age, educational level and the ability of nurses to participate in CNE (P < 0.05). Younger nurses with lower educational level are more difficult to participate in CNE due to personal ability. There is a positive correlation between the length of working experience and the time limitation faced to participate in CNE (P < 0.05). Senior nurses are too busy with their work to participate in CNE due to limited time. Conclusion: The problems faced by active nurses in Tibet in flexible scheduling system, and providing funding or implementing an incentive system, to enhance the confidence of active nurses in participating in CNE.


Introduction
Continuing nursing education (CNE) refers to the content of lifelong nursing education that nurses receive after completing standardized professional training [1] [2]. The emergence of CNE can promote both the personal development of in-service nurses and the national development of medical clinical nursing level in China [3]. In recent years, many medical institutions in various regions of China have carried out CNE activities in various forms, and CNE has been effectively promoted in many places [4]. However, when aiding in Tibet we found that the promotion of CNE in Tibet is facing many challenges. Although the active nurses in Tibet have a high demand for CNE, the nurses have an insufficient understanding of CNE and few opportunities for participating. Tibet is located in the southwestern frontier of China, which is a special geographical location.
However, the economy of Tibet is not well developed and is relatively backward compared to other provinces, and medical education resources are relatively scarce. In this regard, it is necessary to fully understand the current status of CNE implementation in Tibet from the perspective of in-service nurses and provide a reference basis for exploring the formulation of CNE education channels and related policies suitable for in-service nurses in Tibet [5].

Research Object
The research survey was carried out from January to March 2020. The study selected 24 hospitals in Tibet (6 first-class A level hospitals, 10 second-class A level hospitals, and 8 second-class B level hospitals) through a stratified cluster random sampling survey.
The principles of sample size calculation include: 1) To ensure the quality of the survey, the number of nurses participating in the survey in each hospital is ≥20; 2 Calculation formula conforming to sample size: ( )  unwilling or unable to participate in this survey due to other factors. The nurses involved in the study had informed consent to the content of the study, and the study was approved by the ethics of regional hospitals, and the survey content met the requirements of medical ethics.

Investigation Tools
The research adopted a questionnaire survey method.

Method
An electronic link of the questionnaire was sent to the respondents, and each mobile terminal is restricted to fill in the questionnaire only once to avoid repeating; the questionnaire was withdrawn within 2 days from the issuing date, and the questionnaire with consistent answers and logical contradictions was excluded. A total of 678 questionnaires were distributed in the study, and 663 valid questionnaires were received with an effective recovery rate of the questionnaire at 97.78%.

Statistical Processing
SPSS statistical software (version 19.0) was used to analyze and process the data.
Among them, the count data was described in the form of N (%), and the non-normal distribution data was described in the form of interquartile range-median form. Multivariate logistic regression analysis was used analyze the relation between the continuing education needs of active nurses and their personal conditions. P < 0.05 indicates that the comparison is of statistical significance.

General Information of the Respondents
The survey included 663 respondents. The general information of involved active nurses is shown in Table 1. Open Journal of Internal Medicine

Relevance Analysis of the Challenges Faced by Nurses Participating in CNE and Their Personal Conditions
In the study, the personal data of the nurses were used as independent variables, and the difficulties in continuing education (fund limitation, time limitation,     [11] pointed out that the challenges faced in the CNE of in-service nurses include both the subjective and objective reasons of the nurses themselves as well as time constraints. Some other problems include that the content of CNE is not systematic and novel enough, or the forms and methods cannot meet the learning needs of the nurses. The survey in this study suggests that the challenges faced by in-service nurses participating in CNE are: attending training requires their own funding; the nurses have financial difficulties; training time restrictions; difficult nursing scheduling, insufficient nursing manpower restricts learning time; nurses have insufficient capability to participate CNE and lack of confidence. Therefore, funding, time, and capacity limitations are the main issues challenge the current working nurse in Tibet to participate in CNE. Multivariate logistic regression analysis showed that the age, working years and academic level were correlated with the challenges for the nurses participating in CNE. The age and working years of nurses are negatively related to the funding restrictions for participating in CNE, indicating that young nurses with limited working experience had much more difficulties to obtain funds for participating in CNE. The age and educational level of nurses is negatively correlated with the capacity limitations of nurses participating in CNE, suggesting that younger nurses with lower educational levels are more difficult to participate in CNE due to personal capabilities. The length of work experience is positively correlated with the time limitation for nurses participating in CNE, indicating that senior nurses intending to participate in CNE are subject to time constraints. Ni et al. [12] studied the problems existing in the participation of nurses in CNE and found that the main factors affecting the participation of in-service nurses in CNE included busy work, high cost, limited region and disallowed family situation. The results of this study are similar to those of the study; they are both suggesting that nurses' ability and time are the factors that affect their participation in CNE. In the study, only in-service nurses in Tibet were investigated, excluding the influence of regional restriction, but the results also suggested that the age of nurses was also the main factor limiting their participation in CNE.

Countermeasures to Solve the Problem of In-Service Nurses Participating in CNE
The hospital and nursing management should provide increasing support for CNE and strive to explore and improve the strategy of nurses to participate in recommended that hospitals in the Tibetan region consider adopting financial assistance from hospitals or granting financial incentives based on the actual performance of nurses to promote them to participate CNE. Agnew A J et al. [13] showed that learning incentives can help medical students develop self-direction and self-regulation and other learning behaviors, suggesting that the incentive mechanism has positive significance in promoting nurses to participate in CNE. Therefore, it is essential to develop effective mechanisms to encourage nurses in emergency departments to consciously participate in CNE.

Conclusion
The training of grassroots nurses is a key measure to strengthen grassroots health services in our country and effectively promote the implementation of the graded diagnosis and treatment system. Tibet has a special geographical location with inconvenient transportation resulting in difficulties for local patients in seeking medical treatment in other areas. Therefore, it is necessary and of positive significance to effectively improve the technical ability of in-service nurses in Tibet, accelerate the cultivation of regional nursing talents, and improve the quality of medical and health services in Tibet and accelerate the development of medical treatment. This research survey shows that more than half of the working nurses in Tibet believe that there are certain pressures and challenges in participating in the CNE. Their main problems are funding, time and capability.
Specifically, young nurses with limited working experience are affected by restrictions on capability and funding, while senior nurses are mainly limited by time. Our study further reveals that to carry out and implement CNE for the active nurses in Tibet in the future, the local government and hospitals should take many aspects into consideration, such as organization, medical institutions, individual nurse and nurse's family conditions. It is recommended that hospitals and nursing management in Tibet should resolve these challenges through the implementation of flexible scheduling systems, assistance from hospital funding or the implementation of incentive systems, and the enhancement of confidence of nurses participating in CNE. This would provide a practical path for the personalized career development of in-service nurses in Tibet.