Re-Thinking Factors Influencing Registered Nurses’ Compliance to Continuing Professional Development Requirements at a Selected Hospital in Oshana Region, Namibia ()
1. Introduction
The current changes taking place within global healthcare systems have increased the need for Continuing Professional Development (CPD) in order to maintain professional competence (Chong et al., 2011). Healthcare practices and patient care standards are the fields that are steadily evolving along with the changing demands of society (Viljoen et al., 2017). Research shows that nurses are aware that their profession requires lifelong learning, and they perceive the importance of evidence-based practice and express strong desires for continued learning (Price & Reichert, 2017). However, Chong et al. (2014), in their study conducted in Malaysia, found that less than 50% of the nurses attended continuing professional education (CPE) activities. The Malaysian Nursing and Midwifery Board requires nurses to obtain 25 credits in order to renew their practicing licenses. However, in this study, only 40.9% of the participants achieved the required points. The study shows that 30.05% had obtained less than 25 credit points, which excluded them from relicensing (Chong et al., 2014).
Continuing Professional Development (CPD) is defined as the way professionals continue to learn and develop throughout their careers so that they keep their skills and knowledge up to date and are able to work safely, legally, and effectively (Health and Care Professions Council, 2016). Globally, all professionals have recognized Continuing Professional Development (CPD) as a primary method to enhance basic professional education regularly. The healthcare environment has been challenged by the environment, including, among others, globalisation, technological advances and climate changes (Chong et al., 2014). Nurses form the largest group of healthcare professionals globally and provide 80% of direct patient care (Sodeify et al., 2013).
The purpose of CPD is to help nurses to maintain updated skill set in order to remain fit to practice and to respond to the changing technologies and demands of health service delivery (Health Professions Council of Namibia [HPCNA], 2011). Participation in CPD activities is among the most effective methods for nursing workforces to maintain and improve competence and update knowledge and skills (Nayeri & Khosravi, 2013). CPD improves knowledge in ethics that will enhance nursing practice since it will enable nurses to identify ethical problems within nursing, come up with innovative solutions to solve those ethical issues and develop sound ethical beliefs and practices. It is clear that nurses with both professional ethics education and continuing education will be confident in their moral judgments and are more likely to use ethics resources and take moral actions (Osingata et al., 2015).
In nursing practice, CPD is the lifelong process of active participation by nurses in learning activities that assist in developing and maintaining their continuing competence, enhancing their professional practice, and supporting the achievement of their career goals (American Nurses Association [ANA], 2015). Therefore, The International Code for Nurses (ICN) advocates for all nurses to carry personal responsibility and accountability for nursing practice and for maintaining competency by continual learning (ICN, 2012). Registered nurses are required to acquire minimum hours of participation in education and training each year (Chong et al., 2014). Therefore, mandating the compliance of nurses to participate in continuing professional development activities must be seen as a way of sending a message that healthcare is dynamic and nurses must strive to update their skills and knowledge to keep pace with all the changes in a healthcare system (Chong et al., 2014).
1.1. Statement of the Problem
The HPCNA has required all registered nurses to participate in CPD activities, acquiring and developing new skills and attributes which are essential to deal with diversified and rapid changes in health and social (HPCNA, 2011). Little is documented in Namibia about the factors influencing registered nurses’ compliance to CPD requirements of the HPCNA. Therefore, the purpose of this study is to determine the factors influencing registered nurses’ compliance to continuing professional development requirements at a selected hospital in Oshana Region, Namibia.
1.2. Research Questions
The paper is guided by the following research questions:
1) What factors prevent registered nurses’ compliance with Continuing Professional Development requirements?
2) What are the effects of compliance to Continuing Professional Development requirements on registered nurses’ professional practice?
3) What are the strategies that could improve nurses’ compliance with Continuing Professional Development requirements?
2. Methodology
The study employed a quantitative, cross-sectional, descriptive survey design to determine factors influencing registered nurses’ compliance to CPD requirements at a selected hospital in Oshana Region. A descriptive research design was adopted for the collection of information on CPD that could be presented numerically or as individual interpretations (Burns & Grove, 2016). The study population consisted of 318 registered nurses working at a referral public hospital in Oshana Region. Simple random sampling was used to select 177 registered nurses who were selected from various departmental units. In this study, the researcher chose a 95% confidence level and a confidence interval of ±5% in order to capture valid and reliable information. Data were analysed descriptively using both the SPSS version 24, Microsoft excel 2012 and are presented in the forms of tables and graphs.
3. Literature Review
The purpose of the literature review is to assist the researcher to determine factors that influence registered nurses’ compliance with the HPCNA CPD requirements, the effects of registered nurses’ compliance on professional practice and possible strategies that could improve compliance to the CPD requirements. Furthermore, this information serves as a guide when formulating the data collection tool. The review of relevant literature also assisted the researcher to identify gaps of knowledge from similar studies done, on the subject under study. The literature is discussed under the following headings, definition of continuing professional development in nursing, continuing professional development directive and factors influencing nurses’ compliance to CPD requirements.
3.1. Theoretical Framework
A theory is a set of organized ideas that explain a particular phenomenon. Theories are formulated when there is no empirical evidence to draw a conclusion from (Langer & Lietz, 2014). The models are used to facilitate the understanding of concepts and how they relate, it alsoplans the research process to enable a systematic view to these relationships by means of detecting the special relations between concepts. Learning theories explain learning and their application and are a guide for educational systems planning in the classroom and in the clinical training included in nursing. This study is guided by Bandura’s social cognitive learning theory (SCLT). The latter was introduced by Albert Bandura in 1977, who had done much work on social learning throughout his career. Bandura is famous for his Social Learning Theory (SLT) which he has recently renamed, Social Cognitive Theory (SCT). Bandura found that models are an important source for learning new behaviors and for achieving behavioral change in institutionalised settings (Bandura, 1977).
According to Langer & Lietz (2014), this theory is mainly based on cognitive learning. Langer & Lietz (2014) argue that indirect learning occurs which stems from the observation of other people’s behaviours. By means of this learning method, individuals are able to learn the generalised and settled learning structures without the need for trial and error (Bandura, 1977).
Social cognitive theory emphasizes a dynamic interactive process among environmental, behavioural, and personal factors to illustrate human functioning (Langer & Lietz, 2014). Bandura’s theory accords a central role to cognitive processes in which the individual can observe others and the environment, reflect on that in combination with his or her own thoughts and behaviours, and alter his or her own self-regulatory functions accordingly. This view of human interactions and functioning evolved in the work and came to be Bandura’s schematisation of triadic reciprocal causation (Bandura’s Social Cognitive Theory, 1977) as seen in Figure 1.
Therefore, this study is underpinned by Social Learning Theory, which is an extension of social cognitive theory.
3.2. Continuing Professional Development
Healthcare professionals worldwide take part in Continuing Professional Development (CPD) to remain competent in practice, and to ensure they provide high-quality care to patients (Sherman & Chappell, 2018). CPD in nursing is defined by Bryce et al. (2017) as a procedure that is aimed at ensuring that members of the nursing profession maintain their capabilities in practice, not for the purposes of getting a certificate or diploma. Continuing professional development is important to all healthcare professionals. According to Manley et al. (2018), in healthcare CPD is important to ensure that frontline staff, such as nurses’ practice safely and effectively. This requires practitioners to update knowledge and skills regularly to match the changing complexity of healthcare needs.
The HPCNA (2011) prescribes CPD to be the means of enabling professional nurses to maintain and improve their professional competencies. Therefore, the health professionals registered in Namibia are required to maintain a constant commitment to lifelong learning in order to update and develop their knowledge and skills as well for maintaining their ethical attitudes. It is thus important that individual professional nurses complete a series of continuing professional education activities each year. Professional development for professional nurses in Namibia is important as it will protect the interests of the public against inexperienced health professionals, while at the same time promoting the health of all Namibian citizens (HPCNA, 2011).
According to the patient charter of Namibia, patients expect to be treated by professional nurses who are skillful, knowledgeable and competent, and nursing care should take place in a safe environment (Ministry of Health and Social Services [MoHSS], 2016). The Namibian CPD system is monitored by the HPCNA
![]()
Figure 1. Bandura social learning theory.
CPD desk which randomly selects registered professionals twice a year to check for compliance. The latter serves as an external force to motivate registered nurses to keep equipping themselves as it is also clear in Bandura’s framework. A health professional that gets selected is thus obliged to submit all required documents within 21 days of receipt of notification. The names of health professionals who do not comply are sent to the relevant council for noting, in this study referring to the Nursing Council. Therefore, the HPCNA believes that healthcare professionals in Namibia will commit themselves to meet the requirements for continuing professional education with a belief that both health professionals and patients will reap the benefits of professional development. The composition of CPD activities includes the traditional learning experience such as attending workshops, conferences, long and short-term courses (HPCNA, 2011). Therefore, nurses can participate in learning sessions as long as those training are approved and accredited by the Nursing Council of Namibia.
3.3. Importance of Continuing Professional Development
The importance of CPD in the nursing profession cannot be over emphasized. According to Giri et al. (2012), continuing professional development is an essential component in driving successful healthcare systems. High quality nursing care requires up-to-date and evidence-based education, regulation and establishment of standards of practice for nurses (Ryder et al., 2018). As professionals it is essential that nurses seek to deliver the highest standards of patient care. In order to do this effectively, they must keep their skills and competence up to date. Ryder et al. (2018) further suggest that tertiary education is only the initial preparation for the profession but cannot prepare the health professional for all the changes that follow during a nursing career.
3.3.1. Technological Changes and Influence
Nursing care is constantly changing as a result of the arrival of new information and advancement in technology (Ryder et al., 2018). Health technological changes have been occurring over time, and new technology has been invented for diagnostics and screening of diseases. The technological changes and continuing substantive changes in healthcare organisations, and technological advances in the health care system, highlight the importance of ethical competence in nursing which necessitate the need for CPD which helps nurses to remain informed of the new changes in technology (Field et al., 2019). The need for nurses to participate in continuing professional development is therefore growing for them to keep abreast of rapid changes in technology (Pool, Poell, Berings, & Ten Cate, 2016).
Nurses today face increasing change in their practice due to advanced technology and changes in patient’s and client’s needs (DeSilets, 2010). These technological advances have a direct influence on the delivery of healthcare. Therefore, for practicingnurses, much of the advanced care knowledge and skills can be met through participation in CPD activities.
3.3.2. Changes in Disease Patterns
Patterns of diseases are dynamic and change over time. Changing demographics patterns of diseases have significant impact on the health delivery system and resulting in care givers needing to be updated with new relevant skills so they can respond appropriately (Field et al., 2019). Individuals in the profession have to take responsibility of their own education, hence the need for professional nurses to regularly update their skills, for them to the able to inform patients correctly (Uarije et al., 2017).
3.3.3. Information on New Developments
In a study in Kenya on barriers to CPD participation for radiographers, Kanamu et al. (2017), argue that obtaining the qualification is the first step in demonstrating minimum level of competence. The information acquired at obtaining the qualification may not be enough to support an individual throughout their professional life but needs to be supplemented (Chong et al., 2011). The latter is supported by Shahhosseini & Hamzehgardeshi (2014) that knowledge gained from basic professional training for nurses has a half-life of 2.5 years thus must be continuously updated. CPD provides nurses and other health professionals with an opportunity to improve their knowledge and skills to match the dynamic environment in which they operate (Kanamu et al., 2017). Nayeri & Khosravi (2013) acknowledge that participation in CPD activities is among the most effective methods for nursing workforces to maintain and improve competence and update knowledge and skills. Balmer (2012) adds that attending CPD activities increases nurses’ awareness and proficiency in patient care, enhances clinical competency and improves patient outcomes. Therefore, the benefit of updated knowledge and improved patient care, mandatory CPD enables nursing to be credited with the status, authority and autonomy that accompany a profession (Ross et al., 2013).
3.3.4. Enhances Professionalism
Ross et al. (2013) believes that continuing professional programs help professionals to maintain professionalism, retain their jobs, build confidence and support nurses’ professional status. Onyango (2013) carried out a study on nurses’ perceptions on CPD in a public healthcare institution in Kenya and 96% of the participants agreed that CPD programmes help professionals to retain their jobs and support nurses’ professional status. CPD compliance is important as it improves the quality of nursing care, increase nurses’ self-confidence and self-esteem, increase nurses’ motivation and enhanced recognition of nurses among healthcare workers (Brekelmans et al., 2016).
4. Results and Discussion
The possible strategies to improve registered nurses’ compliance to CPD requirements are discussed. Participants had to mark their choice on a Likert scale between 1 and 5 where 1 represented “strongly disagree” and 5 “strongly agree”. These items are discussed separately. The respondents were required to score the activities in terms of: strongly disagree, disagree, I don’t know, agree and strongly agree. For the purpose of this study, strongly disagree and disagree were combined into disagree, strongly agree and agree were combined into agree.
1) Item 1: Need for management to support CPD activities (N = 125)
Management support was one of the proposed strategies to improve registered nurses’ compliance to CPD requirements. Participants had to indicate whether management support would improve compliance to CPD requirements. Participants’ responses are presented in Table 1 below.
Table 1 shows that N = 120 (96%) participants agreed, and N = 5 (4%) disagreed that there is need for management to support CPD activities. The study findings concur with Jooste’s (2012) position that leaders play a crucial role in continuing professional development of personnel as they support them in the fulfilment of their personal and professional learning goals and needs. Leaders, by virtue of their experience, can also serve as mentors for personnel who are engaged in continuing education (Jooste, 2012). The effectiveness and availability of CPD programmes depends on employer and senior management support (Chong et al., 2014). In addition, the need for management to support CPD activities in public and private support in many hospitals was highlighted. This is in line with the social learning of Bandura development which forms the theoretical lens of the study which suggests that the environment in which one works needs to be supportive of such initiatives like CPD trainings for staff members and also reminding the employees (nurses) of the importance of undertaking such an initiative.
2) Item 2: Improvement on campaigns for CPD trainings for nurses within the hospital (N = 125)
Improvement on campaigns towards CPD training was among the proposed strategies that could improve nurses’ compliance to CPD requirements. Participants’ responses were analysed and presented as shown in Figure 2.
As depicted in Figure 2, the combined findings show that N = 118 (94.4%) participants agreed, and N = 3 (2.4%) participants disagreed that more campaigns for CPD trainings could improve attendance of and compliance to continuing professional development requirements among registered nurses.
This means that more campaigns are needed to sensitise nurses on the importance and consistent participation in continuing professional development activities. These findings uphold and support the findings of Day et al. (2018) who
![]()
Table 1. Management to support CPD activities.
recommended that campaigns for CPD trainings for nurses within the hospitals could improve the hospital employees understanding of the role played by CPD training initiatives. Moreover, organisations should work closely with other CPD providers and be part of local CPD networks. Within the context of this study, it would imply for private and public hospitals to combine their efforts on CPD provision, to enhance participation by registered nurses.
3) Item: 3 Reducing nurses’ workloads (N = 125)
Participants were asked to indicate whether reducing the workload of nurses by increasing nursing manpower, would improve the registered nurses’ compliance to CPD requirements. Participants’ responses are indicated in Figure 3.
After the responses as reflected in Figure 3 were combined, it was evident that that N = 26 (20.8%) participants disagreed, and N = 89 (71.2%) agreed that reducing the workloads for nurses within the wards, through increasing nursing manpower, could improve registered nurses’ compliance to CPD requirements. Employers should recruit adequate staff in order to enhance CPD attendance. Moreover, that will allow nurses to attend CPD sessions and obtain the required CPD points, so they can remain in practice (Mnguni, 2018). Therefore, shortage of staff was considered a challenge in complying with CPD requirements.
4) Item 4: Improvement of hospital commitment towards CPD training activities (N = 125)
Improvement on hospital commitment was also among the strategies that could improve registered nurses’ compliance to CPD requirements. Participant’s responses are illustrated in Table 2.
The combined findings in Table 2 will concentrate on the participants who agree on whether the hospital should be more committed toward CPD training. The high number of N = 103 (82.4%) participants agreed that improvement of hospital management commitment towards CPD training activities
![]()
Figure 3. Reducing nurses’ workload (N = 125).
![]()
Table 2. Improvement of hospital commitment towards CPD training activities (N = 125).
would enhance registered nurses’ compliance to CPD requirements. This supports the findings by Mnguni (2018) who indicates that improved coordination of CPD programming or scheduling would enhance the implementation of CPD in a hospital or clinical facility. In addition, Adeniran et al. (2013) indicate that leaders that want better outcomes for their patients must create environments that encourage nurses’ participation in professional development. It is the roles and responsibilities of employers to create an enabling environment to ensure that CPD is supported for all nurses so that they meet their CPD requirements.
5) Item 5: Stakeholder collaboration on CPD curriculum development (N = 125)
With this item participants indicated whether collaboration between stakeholders and nurses on CPD curriculum development would improve the registered nurses’ compliances to the CPD requirements. Their results were analysed and presented as shown in Table 3.
After the findings were combined as indicated in Table 3 it was found that N = 8 (6.4%) participants disagreed and N = 109 (87.2%) participants agreed that stakeholder collaboration on CPD curriculum development could improve CPD compliance. Yan emphasized that CPD is fundamental for staff working in healthcare organizations to provide best practice and optimal patient outcomes. Similarly, Nalle et al. (2010) found that nurses’ practice in CPD has continued to
![]()
Table 3. Stakeholder collaboration on CPD curriculum development N = 125.
gain support by the majority of the state boards responsible for the regulation of nursing in the United States of America (USA). A total of twenty-eight state boards in the USA have embraced and recognised CPD as a means of demonstrating professional competence whereby CPD is used during certification and application for renewal of their practice license. However, to implement CPD, it is necessary to involve policymakers and government administrators to help maintain and sustain CPD into the future. Alsop (2013) maintains that for healthcare workers to be able to provide quality care, the government and other involved stakeholders need to ensure equal distribution of CPD opportunities. Furthermore, Swihart (2017) recommended that employee collaboration on CPD curriculum developmental initiatives would improve the participation of the nurses in activities for CPD. Therefore, it is evident that CPD curriculum content cannot be developed in isolation. A concerted effort among stakeholders to develop shared CPD modules will lead to positive development to CPD compliance. The identification of training needs should include a variety of other stakeholders (Meyer, 2012).
6) Item 6: Financial rewards (N = 125)
Financial rewards were among strategies that could improve registered nurses’ compliance to CPD requirements, as participants’ responses are indicated in Figure 4.
Figure 4 shows that N = 49 (39.2%) participants agreed that giving financial rewards would motivate those who have attended the CPD trainings, N = 40 (32%) participants strongly agreed, N = 22 (17.6%) participants disagreed, N = 4 (3.2%) strongly disagreed and N = 10 (8%) participants were neutral. After the responses were combined, it was clear that N = 26 (20.8%) participants disagreed and N = 89 (71.2%) participants agreed that giving financial rewards as a motivation to those who have attended the CPD trainings, would improve registered nurses’ compliance to CPD requirements. Findings of the study concur with Pool et al. (2016) who indicate that financial reward has been found to greatly influence the degree the CPD participation. Similarly, Taylor (2016) found the influencing factors to be economical gain, job promotion and financial rewards. However, the findings show that nurses’ willingness and readiness are affected by their style of learning, previous learning experiences, familiarity to technology, career fulfilment, and availability of mentoring and support system (Panthi & Pant, 2018).
5. Conclusion
The conclusions are presented according to the research questions of the study. Firstly, the study concluded that there is evidence that the registered nurses of the selected hospital in the Oshana Region tend not to comply with the HPCNA set requirements of accumulating 30 CEUs per annum. Out of 125 participants, a total of 105 (84%) did not comply with the CPD requirements set in Namibia by the HPCNA. The Namibian Health Professions legislation prescribes CPD as the means for maintaining and updating professional competence, to ensure that the public interest will always be promoted and protected, as well as ensuring the best possible service to the community.
Secondly, the study concluded that the majority of the participants do not participate actively in continuing professional development training. This results in a high number of registered nurses not complying with the continuing professional development requirements. This is due to financial constraints; lack of motivation and shortage of staff, which impedes the registered nurses’ attendance to CPD training.
Thirdly, it is concluded that management should support improvement through campaigns for CPD training, reducing of nurses’ workload, improvement in hospital commitment, and collaboration of the CPD curriculum developers (HPCNA) with registered nurses could help to facilitate attendance to CPD sessions. In addition, financial rewards may also improve the registered nurses’ compliance with CPD requirements. The study concluded that there is an association between age, gender, and CPD attendance, however, there is no association between marital status, years of experience, the highest level of education, and CPD attendance.
6. Recommendations
The study recommended that: institutions of higher learning: Emphasize the importance of compliance to CPD requirements in the curriculum on professional practice.
· Strengthen the collaboration among institutions in order to share efforts on presenting CPD sessions.
· Implement training to employees within the quality assurance department of hospital to equip them with the necessary skills to offer CPD sessions.
· Establish a CPD training team with representatives from institutions to develop a nationwide online schedule with corresponding content to support practicing registered nurses to comply with CPD requirements.
The following were recommended for further research:
· Compare the registered nurses’ competence with CPD attendance.
· Employ a qualitative methodology in further studies to obtain individual opinions on the CPD system.
· Replicate the study in other regions where variables may differ.