A Survey on the Continuing Education Status and Demand of Nurses in Chongqing Grass-Root Medical Institutions

Background: With the increased aging of population, the continuous increase in the morbidity of chronic diseases, and the issuance of universal two-child policy, the grass-root medical teams become more and more im-portant. Objective: To investigate the continuing education status and demand of nurses in the grass-root medical institutions and thus provide a reference for optimizing the continuing education plan. Methods: From October 2018 to May 2019, a survey of 270 nurses from 28 grass-root medical institutions in Tongliang District of Chongqing was performed using a self-designed questionnaire. Results: In the grass-root medical institutions, the major continuing education pattern of nurses was hospital training and distance education; the continuing education focused on new basic theoretical knowledge and new nursing techniques, and its satisfaction was 67.8%. About 20.6% questionnaire answerers never had received continuing nursing education. As shown by one-way analysis of variance (ANOVA) and binary logistic regression analysis, the following factors were associated with the continuing education participation in the past three years: work unit, organizational affiliation, age, professional title and hospital policies. There were 93.0% questionnaire answerers reflecting that it was necessary to participate in the continuing education and wishing the conformance between the pattern and contents of continuing nursing education and the actual implementation status. Conclusion: The continuing education demand of nurses in the grass-root medical


Introduction
With the change of disease spectrum and the increased aging of population, "strengthening the gross-root" becomes one of keys in the new medical reform.
The gross-root nurses, as a member of the medical technician team, play an important role in the hierarchical diagnosis and treatment, chronic disease management, geriatric nursing, and community service; however, they have differential core competencies, and there is an imbalance of overall horizontal development [1] [2]. To promote the service level and improve the nursing quality, the nurses must keep receiving the continuing education in the whole professional career [3]. As mentioned in the "13 th five-year" national medical and family planning talent development plan, the targeted continuing medical education (CME) of multiple patterns for all kinds of medical and family planning technicians (e.g., traditional Chinese doctors, pharmacists, nurses and technicians) in the urban and rural gross-root medical institutions shall be enhanced to increase the post competence. The domestic investigators have completed many studies of continuing education in the grass-root nurse teams, but these studies focus on different topics. This study aimed to investigate the continuing education status and demand of nurses in Chongqing gross-root medical institutions and thus provide a reference for the development of optimal continuing education plan.

Study Objects
The gross-root medical institutions of lower than the district level in Tongliang District of Chongqing were selected from October 2018 to May 2019, including 5 community health service centers and 23 township hospitals, but excluding the village clinics with <3 nurses. A survey was performed on 270 nurses. The inclusion criteria were described as follows: 1) registered nurses with nurse licenses; 2) nurses who had engaged in the grass-root nursing work for ≥1 year. All nurses were voluntary to participate in this survey.

Survey Tools
This survey was conducted using a self-designed questionnaire. The questionnaire included three parts: 1) personal general data, including work unit, sex, age, post, professional title, education, organizational affiliation, and so on; 2) continuing nursing education status, including continuing education participation in the past three years, satisfaction to continuing education efficacy, reasons for no or rare participation in the continuing education, and unit support; 3)

Data Collection Methods
We successfully sought for the cooperation and assistance from Department of Medical Administration, Tongliang Health Commission. Firstly, a questionnaire pre-survey was performed and then the questionnaire was modified according to the problems found in the pre-survey. Secondly, a survey was conducted by convenient cluster sampling. Totally 270 questionnaires were distributed to various grass-root medical institutions in the whole district and then uniformly filled by study objects under the organization of Department of Medical Administration, Tongliang Health Commission. To guarantee the questionnaire filling quality, the investigators adopted the uniform instructions and provided the detailed statement about the survey significance and the contents, filling and notes of questionnaires. Finally, 256 (94.8%) eligible questionnaires were collected.

Statistical Analysis
SPSS 21 software was used for statistical analysis. The qualitative data were analyzed by descriptive statistics with frequency and percentage. For continuing education participation in the past three years, the demographic data and work data of participation group and non-participation group were compared using x 2 test. The factors related with continuing education participation were analyzed by binary logistic regression analysis; the variables were screened by forward selection, backward elimination and enter regression, and then the screened differential variables were included into the final regression model. For variable screening, the inclusion and exclusion criteria of variables were both p = 0.05.
The co-linearity among independent variables was diagnosed with the variance inflation factor, and the variance inflation factor < 5 indicated no co-linearity.
The significance level for all analyses was p < 0.05.

"Blind Zone" of Continuing Education
In the investigated nurses from the gross-root medical institutions, 20.6% never had received continuing nursing education, of which 96.2% were aged ≤ 35 years, 82.7% had ≤ junior college education, and all had professional titles of ≤ senior nurse.

One-Way ANOVA
With continuing education participation in the past three years as grouping variable, the following factors were included into the statistical analysis: work unit, sex, age, professional title, post, education, organizational affiliation, unit support, and hospital policies ( Table 2). The factors related with the continuing education participation in the past three years were work unit (p = 0.004), organizational affiliation (p < 0.001), age (p < 0.001) and professional title (p < 0.001). It indicated that more nurses working in the community health service centers and with a bigger age, a higher professional title and "established" organizational affiliation participated in the continuing nursing education.

Binary Logistic Regression Analysis
The setting of variables was same as the above, i.e., work unit (community health service center, OR = 0.09, p < 0.001; reference variable: township hospital), organizational affiliation (established, OR = 0.02, p < 0.001; reference variable: Bachelor education), and hospital polices (p = 0.008; reference variable: satisfactory). The results are shown in Table 3. This further indicated that more nurses working in the community health service centers, with "established" organizational affiliation and who had higher satisfaction to hospital policies participated in the continuing education.

Continuing Education Demand of Nurses in the Gross-Root Medical Institutions
In all questionnaire answerers, 93.0% reflected that it was necessary to participate in the continuing education. The purpose of continuing education participation   was "acquiring the professional knowledge" (68.4%), "improving the operation skills" (58.8%), and "conferring of professional titles" (33.2%). The continuing nursing education pattern was expected to be distance education (69.7%), hospital training (68.9%), and academic conferences/lectures (35.9%). The continuing nursing education contents were expected to be new nursing techniques (81.7%), new basic theoretic knowledge (73.7%), and nursing safety (57.8%) ( Table 4).

Overall Analysis
The demographic data showed that the grass-root nurse team were young and had low professional titles and low education, which is consistent with the study results of Fu Lili and Chen Shengyu et al. [4]. The continuing education pattern was mainly hospital training and distance education, because they were more convenient than academic conferences, advanced education and other resource acquisition channels, required less time and low costs, and were easier for units to organize and implement. The continuing education contents focused on new basic theoretic knowledge, new nursing techniques and nursing safety, maybe because most grass-root nurses had ≤ junior college education and ≤junior professional titles. The nurses had low satisfaction to the efficacy of continuing education, and only 2/3 of them felt satisfactory, which is lower than the study results of Miao Maoyun and Zhang Xiangfeng et al. [5]; the possible reason is that the grass-root medical institutions provide few standard and systematic nurse training platforms and channels for nurses [6]. Based on the survey results,

Analysis of "Blind Zone"
As shown by the survey, 1/5 grass-root nurses never had received continuing nursing education in the past three years, and their demographic data indicated that over 90% were aged ≤ 35 years and had ≤ junior professional titles, they were the young strength of the grass-root nurse team, and their professional quality was closely associated with the overall service level of grass-root nurses [8]. These nurses become the population to be forgotten when the continuing education activities are carried out, so the organizations shall pay importance and actively take measures to eliminate the "blind zone". The factors influencing the continuing education participation included work unit, age, professional title, organizational affiliation and satisfaction to hospital policies. All 5 community health service centers were all in the county urban area and had a bigger distance advantage than township hospitals in obtaining the continuing education resources from the district people's hospital and other superior hospitals; meanwhile, their service objects were more than those of township hospitals, which gives stronger external motivation of learning to the nurses [9]; thus, compared with township hospitals, more nurses working in the community health service centers participated in the continuing education activities. Furthermore, the nurses with high professional titles had a higher professional foundation and higher self-orientation [10], and most of them were paid importance in cultivation by the hospitals and leaders together with the established nurses; thus, these nurses had more chances to participate in the continuing education. In the satisfaction to hospital policies, higher continuing education participation initiative of nurses depends on more importance to the capability promotion of nurses, more support to the continuing education participation of nurses, and more excellent incentive measures from the hospitals. It is easily seen that the work unit, age, professional title and organizational affiliation are relatively fixed and difficultly changed in a short time, while the hospital policy measures can be conveniently taken to influence the continuing education participation of grass-root nurses. Therefore, the leadership can fully consider the influence of the nurse team during the policy development process to encourage the continuing education behaviors.

Analysis on the Continuing Education Demand of Nurses in the Grass-Root Medical Institutions
Over 90% grass-root nurses believed that it was necessary to participate in the continuing education activities, which is slightly higher than the percentage in the study of Miao Maoyun and Zhang Xiangfeng et al. [11]. It may be somewhat associated with the national policy incline to "strengthening the grass-root" since the 13 th five-year, and shows that the grass-root nurses have a positive attitude to continuing education and can be fully aware of continuing education importance, but there is still a certain space for promotion. The purpose of continuing education participation was mainly "acquiring the professional knowledge" and "improving the operation skills", which indicates that under the social background of an increasing chronic disease morbidity, population aging, and two-child policy issuance and facing the day-by-day increasing health demand of people, the grass-root nurses know their defects in professional knowledge and professional skills and wish to promote their professional service capability by continuing nursing education. The desired continuing education pattern was mainly distance education and hospital training, which is coincident to the actual implementation pattern. Most grass-root nurses in this study were aged ≤ 35 years, which is just a peak age group of childbirth and education and also a key period of vocational development. Combining the above analysis showing that the nurses complained about busy work for no or rare participation in the continuing education, the continuing education pattern of a short time, a small distance and rapid access is expected. The desired continuing nursing education contents were new nursing techniques, new theoretic knowledge and nursing safety, which is similar to the actually acquired contents; however, the desired contents proportion was significantly higher than the actual contents proportion. This suggests that the continuing education demand of grass-root nurses is basic and becomes diverse gradually, and the actually implemented continuing education activities cannot meet such demand, so the organization departments shall enlarge the width and depth of continuing education contents.

Conclusion
The nurse teams in the grass-root medical institutions are generally younger and have low education, low professional titles, and low satisfaction to the current continuing education activities. And their demand for continuing education is basic and dominantly focuses on basic theoretical knowledge and operation skills, but demonstrates diversity. Therefore, the organizations shall provide effective policy support for continuing education and make the diversified training plan by combining Internet technology, so as to realize the maximization of continuing education participation and keep improving the overall service quality of gross-root nurses.

Human Resource Support
Since the implementation of new medical reform, the grass-root nurses bear heavy work and their nursing scope is gradually enlarged, while insufficient human resources restrict the promotion of nursing service level and the participation of continuing education to a certain degree [12]. Therefore, the leadership shall fully consider the demand, enrich the human resources of grass-root nurses, optimize the post configuration, and reduce the waste of human recourses; meanwhile, the leadership shall provide more learning convenience for nurses under the current conditions by flexible shift arrangement and learning time supplementation to increase the continuing education participation.

Policy and Institutional Support
Despite an awareness of the importance of continuing nursing education, the grass-root management departments fail to establish the systematic and standard continuing education procedures, and there are different assessment systems in various regions [13]. Partial nurses only participate in the continuing education for getting credits, and it is suggested that the competent units complete the continuing education training system of grass-root nurses and realize the urban-township equal and homogenous training modes and assessment systems. In addition, these units are suggested to enlarge the incentive strength to provide reimbursement for learning funds and promotion chances for encouraging the active participation of nurses, thus achieving the full coverage of continuing education and maximizing the utilization and stabilization of the current grass-root nurse team.

Network Technical Support
The development of Internet offers a new possibility of learning. The studies have shown that Internet-based learning can enhance the training efficacy and has such advantages as no geographic limitation, effective realization of training resource sharing, and training time saving [14] [15] [16]. The relevant departments shall actively explore the training modes meeting the demand of the times, positively make a response to "Internet + nursing", and create a "digital and mobile" ubiquitous learning platform and resources to be accessed at any time and at any place by such means as remote network, teleconference, CD-ROM, WeChat, QQ group and app [17] [18], so that the nurses have no worries about the training quota, traveling time and funds and can make full use of fragmented time, thus eliminating the work-learning conflict and realizing the purpose of training without "a long trip".

Content Resource Support
The demand of nurses for continuing education contents in this study was in a primary stage but demonstrated diversity, perhaps because the work scope of nurses in the grass-root medical institutions gradually extended to the prevention of chronic diseases, geriatric nursing, health education, prevention and health care, and psychological nursing. The leadership departments shall pay importance to the learning demand of nurses, work out the training contents with such demand as guidance, increase the fund input of open learning resources, break through the task-based learning thinking of "non-conformance with the actual work" and "learning just for learning", and practice the continuing nursing education using several education patterns to really promote the overall quality of grass-root nurses.

Personal Level
The grass-root nurses shall improve the self-efficacy and internal learning motivation [19], establish a life-long learning idea, positively acquire the learning resources using multi-dimensional learning channels [20], and coordinate the conflict between family and learning; besides, they shall widen the learning contents on the basis of mastering the basic theories and basic skills to continuously meet the demand of people and facilitate the realization of "everyone has access to health care services". Our study contents and data are true and reliable. However, this study has some limitations below: only the nurses from the grass-root medical institutions in a district of Chongqing were selected as study objects, and there was a small sample size.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper. Open Journal of Nursing

Questionnaire for A Survey on Continuing Education Status of Nurses in Chongqing Grass-root Medical Institutions
To whom it may concern, This is an anonymous questionnaire to investigate the continuing education status of nurses in the grass-root medical institutions, and there are no wrong or correct answers. Your answers will be only used for academic research but not published. Please fill the questionnaire according to your actual situation and honest opinions.