Continuing Professional Development: Needs, Facilitators and Barriers of Registered Nurses in India in Rural and Remote Settings: Findings from a Cross Sectional Survey

Background: Nurses constitute a major portion of the health care workforce in India. A priority to develop pre and post registration nurse education in India has increasingly been highlighted in nursing and health policy imperatives in recent years. Nurses are often the only health care professionals in primary and secondary care within rural and remote healthcare settings in India. They are confronted with the dual challenge of resource constraints and rapidly changing disease profile with little or no access to continuing professional development. Objectives: 1) To identify key continuing professional development priorities of registered nurses working in remote and rural health care settings in India. 2) To identify barriers and facilitators to continuing professional development as perceived by registered nurses working in these settings. 3) To identify preferred modes of continuing professional development by registered nurses working in remote and rural health care settings in India. Design: Quantitative Design. Setting: Two large health care facilities in remote and rural parts of India. Participants: Registered Nurses working in two large not for profit health care organisations participated in the study. Nursing assistants and student nurses were excluded from the study. 368 participants consented to participate in the survey and 271 (73.6%) participants completed the survey. Methods: A questionnaire based cross sectional survey was undertaken as part of the Continuing Professional Development needs assessment among registered How to cite this paper: Macaden, L., Washington, M., Smith, A., Thooya, V., Selvam, S.P., George, N. and Mony, P.K. (2017) Continuing Professional Development: Needs, Facilitators and Barriers of Registered Nurses in India in Rural and Remote Settings: Findings from a Cross Sectional Survey. Open Journal of Nursing, 7, 930-948. https://doi.org/10.4236/ojn.2017.78069 Received: July 18, 2017 Accepted: August 27, 2017 Published: August 30, 2017 Copyright © 2017 by author and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/


Introduction
Nurses constitute a major portion [38%] of human resources within the healthcare system in India [1]. A priority to develop nurse education in India is increasingly highlighted in nursing and health policy imperatives in recent years [2].
Nurses in India face challenges that can be viewed within the global context, with shared solutions to problems becoming increasingly relevant. Demographic transition, the looming non-communicable disease [NCD] epidemic in India, national health priorities such as reduction in child and infant mortality yet to be achieved, the delay in the improvement of maternal health of the Millennium Development Goals [MDG] [3] and India becoming a recent signatory to the sustainable development goals all signpost an imminent changing role for nurses [3] [4]. Given the paucity India has on health care outcomes that are strongly influenced by political-socio-economic factors, gender, education and geography and inequalities in health services [4], it is vital that relevant Continuing Professional Development [CPD] programs for nurses are developed to help mitigate some of the challenges to effective healthcare delivery.
"Continuing professional development (CPD) helps health professionals to maintain, improve and broaden their knowledge, expertise and competence" [5].
A recent needs assessment of preparedness of facility and personnel for man-  [6]. These gaps raise major concern since nurses are often the first point of contact or only professional contact for populations in remote and rural parts of India. The development of relevant and co-produced continuing educational programmes for health care professionals is vital through engagement with related stakeholders [7]. Lack of consistent and structured nurse education at pre-and post-registration levels, poor access to a contemporary and robust evidence base, lack of standardised/accredited training programmes and protocols to acquire and evaluate skills have all been highlighted as key reasons for poor quality of care delivery [7] [8] in India. Given that knowledge gained through basic education has a half-life of 2.5 years [9], it is important that CPD training programmes that are both contextually relevant, and accessible [10] [11] are developed creatively.
Recruiting highly qualified health care professionals to rural, remote, and underserved areas in India is very challenging [2]. Because of the shortage of doctors in these settings, there is an expectation that nurses substitute for this deficiency and provide the required care [12] [13] [14]. It is therefore important that nurses, who choose to work in such settings have access to CPD programmes that regularly update both knowledge and clinical skills required to initiate standard management, recognize complications early, provide initial treatment and make appropriate and prompt referrals. Nurses in these settings also play key roles in health promotion and prevention of illnesses but this role might require strengthening. Planning CPD programs that are contextualised to local and national needs with robust quality, relevance and accessibility to facilitate change in professional practice is imperative for nurses in these settings, so that they can contribute to the health care outcomes of the communities they serve [2] [15]. Additionally, the professional development and career progression needs of nurses need to be considered when developing CPD programs [16], as nurses will also assume managerial roles alongside their clinical responsibilities in clinical or public health settings.
The Indian Nursing Council [INC] has recently made CPD mandatory towards the renewal of professional registration and has stipulated a minimum of 30 credit hours per year or 150 hours of CPD related activities over 5 years [17]. It is therefore timely and appropriate to explore the CPD needs of nurses working in remote and rural settings given the current lack of structure, and the paucity of literature in this area through a formal needs assessment to inform relevant program design and delivery. Additionally a co-produced CPD strategy developed with nurses and stakeholders working in remote and rural settings would help robustly validate content and relevance of CPD for nurses [18].
This paper aims to describe findings from a formal needs assessment that was undertaken to explore the CPD needs of nurses working in two not for profit large health care organisations in remote and rural India.

Aims:
1) To identify key CPD priorities of registered nurses working in remote and rural health care settings in India.
2) To identify barriers and facilitators to CPD as perceived by registered nurses working in these settings.
3) To identify preferred modes of delivery for CPD by registered nurses working in remote and rural health care settings in India. Sample selection: Participants were purposively chosen using the criteria be-

Recruitment of Participants
The administrative heads and study coordinators from both organisations were

Data Analysis
For analysis, scores were reversed such that very confident was assigned 4, confident was 3, confident with support was 2 and lack of confidence was 1. Scores were obtained by the aggregate of the self-assessed rating of participants to items Competencies where more than 70% of participants reported confidence were not considered as a CPD priority for training. CPD needs were identified as a priority only if more than 30% of participants reported low levels of confidence with any particular competency.
Descriptive statistics were reported using number and percentages for the categorical variables and the continuous variables were reported using mean ± SD and median [Q 1 , Q 3 ]. Assumption of normality was assessed using Q-Q plot. Clinical competencies, managerial competencies and their domain scores were compared between baseline variables such as type of institution [

Results
Participant Characteristics: From among the 247 participants, 217 (88%) of them were staff nurses and women. Nearly two third of the participants [62%] had a diploma in nursing and midwifery, 30% of them had a Bachelor's degree and 17.7% had a Master's degree. The overall median years of experience was 3.5 years.
Participants were also reported. Self-assessed competency scores were not significantly different between any of the baseline variables except for the number of hospital beds [ Table 2]. Nurses who participated from hospitals with less than 50 beds had lower self-assessed competency scores in their overall clinical competency score, management of acute clinical emergency and management of NCD scores than those from hospitals with >50 beds.
Managerial Competencies: CPD priorities for the following managerial competencies [       of the participants preferred CPD to be both within and outside their organisa-

Discussion
Empowering nurses with knowledge and competencies to be able to provide relevant and safe health care is an imminent need particularly in rural and remote   settings in India, where resource constraints are acute. One way this can be best achieved is through regular CPD training since knowledge and skills gained whilst training to be a nurse could be redundant in less than 5 years [9] given the complexities of health care needs and changing demographic profile of the country.

CPD for Clinical and Managerial Competency Building
Nurses from the two health care networks that operate primarily in remote and rural India, reported that their clinical competencies require strengthening in two main areas: 1) management of acute and long term NCDs; 2) obstetric and  [20]. Nurses in this study indicated the need to strengthen their ability to provide health promotion activities relevant to NCDs. This is an important finding as several of the risk factors for NCDs could be modified with concerted efforts [21]. The rapid "health transition" globally and in India and the double burden of communicable and NCDs calls for a more dynamic nursing role both in primary and secondary care in remote and rural health care settings [19] [20] [21]. It is therefore necessary for CPD training programmes to have a more intense focus on prevention than a skewed emphasis on high tech medical environment with mounting costs for treatment for NCDs [22]. CPD programs thus need to focus on the global action plan for the prevention and control of NCDs targeting health promotion on the four shared behavioural risk factors that include tobacco use, unhealthy diet, physical activity and alcohol abuse [20] [23] [24]. Given the strategic location of the nurses in this study, and the acute shortage of health care professionals where they work, enhancing their capability to relate to the contextual influences on the health illness continuum and health seeking behaviours of people at risk for NCDs could possibly influence the health outcomes of the community and the country at large. This focus would be in line with the voluntary global targets of 25% reduction in risk of premature mortality from NCDs, a 10% relative reduction in prevalence of insufficient physical activity, and a halt in the rise of diabetes and obesity [20] [24] [25].
Nurses in this survey have clearly reported their preferred mode of CPD is through skills training. Skills to identify obstetric and new born emergencies, initiate immediate treatment and make prompt referrals could be key to improving maternal and new born outcomes in these settings [9]. This could be done by emergency drills or simulations to evoke a coordinated team response [9] [26]. It is also important to take cognisance of the fact that with increasing years of experience, nurses reported lower levels of clinical competence [p < 0.01]. This might imply a need for CPD programmes to target relevant clinical competencies for experienced nurses.
Alongside clinical competencies, knowledge of Quality Improvement [QI], performance appraisal, clinical audits and conflict management were identified as some key managerial competencies for development. Paradoxically ate qualification reported to be managerially more competent than those with a diploma, possibly due to management training in their nursing curriculum. However, attempts to strengthen both clinical and managerial competencies through CPD must be carefully balanced based on one's clinical and or management roles.

Facilitators and Barriers to Attending CPD
CPD programs are critical to enhance the quality and safety of care provided by nurses in addition to promoting job satisfaction and staff morale [7] [26]. Various reasons are reported for CPD attendance including, job satisfaction, staff morale and patient safety [9], performance appraisal or personal development, career and performance improvement [4]. These findings suggest that both personal/career development and practice improvement feature significantly. Nurses in this survey similarly reported that they attended CPD training largely for their professional development needs and their personal interest, and also interestingly as an opportunity for socialising. Nurses working in remote and rural areas can often feel isolated from their fellow professionals and it important to recognise this factor while developing CPD training opportunities. Barriers to attending CPD training mostly included personal reasons such as domestic responsibilities, distance, cost and professional reasons such as work commitment, staff shortage and lack of information. Similar barriers to CPD attendance have been found elsewhere; including, lack of time and finance, access to CPD [4], difficulty balancing work, continuing education, and home life [18] [27]. Therefore, to maximise participation in CPD, it is important that an environment is created for nurses to be able to participate interactively taking into account nurses' professional, personal and social needs. This approach is borne through evidence and studies have shown that strong organisational support, such as paid study time, strong leadership and a positive attitude to CPD from both management and peers facilitates effective learning [12] [13].
Too often, the ambiguity, challenges and complexities faced by nurses in the acute care practice environment are not addressed by theoretical learning [28]. It is also interesting to note from the survey results, that even though participants mostly attended conferences, in house CPD sessions and case reports, they preferred skills training for the CPD needs identified. It is therefore essential that whilst planning CPD training it would be beneficial to involve all stakeholders especially staff nurses with an emphasis to promote quality patient outcomes, critical thinking, clinical reasoning and expert judgement [16] [28] for their autonomous practice in these settings.
The merit of mandatory CPD on personal and professional development is debatable primarily since there is paucity on literature of the intended purposes of CPD [29]; CPD is often not prioritised because of predetermined professional or personal plans, lack of equity in terms of access, and staff nurse shortages [16] [26] [30]. Until recently, CPD has not been mandatory for maintaining an active nurse or midwife registration in India. For CPD training programmes to be re-  [33]; they should also create avenues for career advancement, rather than being incidental, inflexible, ad hoc and a "tick box" exercise to ensure an active nurse/midwife registration [28] [33] [34]. CPD activities are rarely evaluated in the context of their long term impact on practice or professional development. Since there is a lack of evidence around the impact of CPD programmes now coupled with regular CPD training being made mandatory towards maintaining professional registration for nurses in India, it is appropriate to explore developing models that are locally and contextually relevant to assess the impact of these training programs.

Limitations
1) Findings from the study may have been enhanced by in depth Focus Group discussions with participants around some of the survey findings. However, this was not possible due to the restrictions with the duration of the project [9 months], limited funding and geographical distances that needed to be covered.
2) Questionnaires were distributed by designated coordinators within both organisations which may have influenced recruitment of the participants to the study. However, this was overcome by obtaining individual informed consent forms from participants in the study.
3) Questionnaires were only made available in English due to lack of funds for translation and most participants' first language was not English. However, nurse education in India is delivered in English and coordinators from both institutions were proficient bilingually in Hindi and English and were available for any interpretation if participants required.

Conclusions
To our knowledge, this is the first ever needs assessment undertaken on nurses' CPD training requirements in remote and rural health care settings in India.
Health care professionals in sufficient numbers, in the right places, adequately trained, motivated and supported are identified as the backbone of an effective, equitable and efficient health care system [13]. For CPD programmes to be effective, they need to be responsive to both professional and personal needs and more importantly reflect strategic health priorities of a nation. Taking the cue from the WHO's need to rejuvenate primary health care [35], if CPD is needs assessed and co-produced with nurses for their professional development [16] and to promote health within the communities they serve, there is an opportunity for them to carve a niche towards their professional identity and earn recognition for their services [32].