Nurse Education in Practice

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1 Nurse Education in Practice 10 (2010) Contents lists available at ScienceDirect Nurse Education in Practice journal homepage: A systematic review evaluating the impact of post-registration nursing and midwifery education on practice q Harry Gijbels *, Rhona O Connell, Caroline Dalton-O Connor, Moira O Donovan Catherine McAuley School of Nursing and Midwifery, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, Ireland article info summary Article history: Accepted 20 March 2009 Keywords: Post-registration education Systematic review Evaluation Evidence based practice Given the current focus on evidence-based practice, it is surprising that there is a dearth of systematic evidence of the impact on practice of post-registration nursing and midwifery education. The systematic review presented here formed part of a national review of post-registration nursing and midwifery education in Ireland [Health Service Executive, Report of the Post-registration Nursing and Midwifery Education Review Group: Changing practice to support service delivery. Health Service Executive, Dublin]. The review focuses specifically on the impact on practice from the perspective of nurses, midwives, patients, carers, education and health service providers. Sixty-one (61) studies met the criteria set. These studies were mainly of a retrospective and descriptive nature, often with small cohorts, set within one educational setting. The findings indicate that students benefit from post-registration programmes in relation to changes in attitudes, perceptions, knowledge and in skill acquisition. There is also some evidence that students apply their newly acquired attitudes, knowledge and skills. There is however limited evidence of the direct impact on organisational and service delivery changes, and on benefits to patients and carers. It can be concluded that the impact of post-registration nursing and midwifery education on practice has yet to be fully explored through a more systematic and coherent programme evaluation approach. Ó 2009 Elsevier Ltd. All rights reserved. Introduction q This paper was presented at the 2nd International Nurse Education Conference Research and Innovation in International Nurse Education 9-11 June, 2008, Dublin, Ireland * Corresponding author. Tel.: ; mobile: address: (H. Gijbels). Major trends, driven and influenced by socioeconomic factors, ongoing developments in healthcare, and professional issues unique to nursing and midwifery, have been identified as likely to impact on future changes in nursing and midwifery education, especially at a post-registration level (Department of Health, 2006; Heller et al., 2007; Health Service Executive (HSE), 2007). The ability of health care systems to respond to changes, to maintain and improve quality, efficiency and equity of services, is dependent on appropriately trained and supported healthcare professionals who are available where and when they are needed (World Health Organisation (WHO), 2002). Although the availability of post-registration nursing and midwifery education programmes continues to grow, the benefits to students, employers, patients, and the overall impact on practice remains unclear (Pelletier et al., 2003; Griscti and Jacono, 2006). Against this background a review group, set up by the Irish Health Service Executive (HSE) to develop a new post-registration nursing and midwifery education strategy (HSE, 2008), commissioned a systematic review of post-registration nursing and midwifery education research. The review focused on nursing and midwifery education programmes leading to recognised academic awards such as higher or post-graduate certificate or diploma, masters and doctoral education programmes. It excluded continuous professional development (CPD) and in-service training programmes and activities. This paper reports on one aspect of the systematic review, focusing on a review of studies which investigated and evaluated the impact of post-registration programmes from a nurse, midwife, patient, carer, education and health service perspective, including whether such programmes offered value for money. Methodology A systematic search of the literature was undertaken in March April 2007, using relevant search terms in various combinations (Table 1). Reference lists of retrieved papers were reviewed for additional studies. Although inclusion and exclusion criteria were discussed in advance, these were amended and expanded as the initial search results emerged. Searching and analysing papers raised a series of methodological and conceptual questions around the concept of continuing education. Not only were the terms continuing education, Continuing Professional Education, and Continuing Professional Development used interchangeably, their meaning varied and was not always clarified. Some interpreted this as all forms of structured and planned educational activities, including /$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi: /j.nepr

2 H. Gijbels et al. / Nurse Education in Practice 10 (2010) Table 1 Search strategy and evaluation of studies. Databases searched Search terms Checklist for studies (adapted from Brooker and Brabban (2004)) Barr s et al. (1999) evaluative framework Classifying of research evidence Cinahl, PubMed, ERIC, Academic Search Premier, Science Direct, Blackwell Synergy, Cochrane nurs *, educat *, nursing education, midwi *, postregistration, post-registration, post registration, postgraduate, postgraduate, post graduate, masters, doctora *, post-doctora *, post doctora *, outcome *, evaluat *, impact, competenc *, public health nurs *, community health nurs *, health visit *, intellectual disability *, learning disability *, psychiatric * Paper number, author, country of origin, year, focus of education, length of education full time/ part time, type of education/level of education, study design, aims, sample and response rate, key findings, comments, Barr s level and type of evidence Level 1: Learners reaction the learners views of their learning experiences and satisfaction with their training and education Level 2: Changes in attitudes and perceptions to changes in attitudes and perceptions towards patients and carers, their needs, circumstances, care and treatment Level 3: Acquisition of knowledge and skills the acquisition of concepts, procedures and principles of working with specific patient groups, and the acquisition of critical thinking and problem solving, intervention skills, and team working skills Level 4: Changes in behaviour implementing learning in the workplace, as a result of changes in attitudes and perceptions, or the application of newly acquired knowledge and skills Level 5: Changes in organisational practice wider changes in health care delivery Level 6: Benefits to patients and carers improvements in the health and well being of patients and carers Type 1: Evidence from at least one well designed randomised controlled trial or a systematic review of multiple well designed random controlled trials Type 2: Evidence from at least one well designed controlled trial without randomization Type 3: Evidence from published well designed trials without randomization, single group pre-post, cohort, time series or matched case controlled studies Type 4: Evidence from well designed non-experimental studies from more than one centre or research group Type 5: Opinions of respected authorities, based on clinical evidence and experience, descriptive studies, reports post-registration and post-graduate education delivered by higher education institutes, some excluded post-registration and postgraduate education, some used an all-encompassing term to cover any self-directed initiative that nurses and midwives might take, whilst a fourth group did not clarify the meaning at all. The following inclusion and exclusion criteria guided the search: Inclusion criteria Research papers, literature reviews, systematic reviews, theses and conference proceedings which evaluated the impact of post-registration nursing and midwifery education programmes from a nurse, midwife, patient, carer, education and health service perspective. Continuing Professional Education (CPE) and Continuing Professional Development (CPD) studies which included post-registration education offered by third level institutions. Papers published in English between 1990 and Exclusion criteria CPE and CPD in-service courses, workshops, self-directed study, and studies where CPE or CPD terms were not clearly defined. Studies which lacked clarity or detail about the setting of the course. Studies which explored the potential impact of post-registration education. Studies which evaluated multidisciplinary courses in which nurses and midwives were not differentiated in the findings or where details of participants were not provided. Studies which evaluated non-nursing or non-midwifery postgraduate programmes which nurses and midwives had attended. Assessment of the studies A review of abstracts determined whether full texts of the studies were retrieved. The inclusion of studies was considered by at least two reviewers. To ensure consistency, the process was guided by an adapted version of Brooker and Brabban s (2004) checklist. This initial assessment reduced the volume of papers from 346 to 97 papers. Barr s et al. (1999) evaluative framework provided the conceptual and analytical framework in which the studies were reviewed (Table 1). This consists of six levels of outcome for educational programme evaluation. The decision to use this framework was informed by a similar approach adopted by Brooker and Brabban (2004). While some studies evaluated one aspect of the programme e.g. learners reactions (Level 1), others included more than one outcome, such as evidence of change in attitudes (Level 2), changes in organisational practices (Level 5), and patient and carer outcomes (Level 6). Studies were also examined on the nature of the research evidence, using established criteria for classifying research evidence (Table 1). While 97 papers were included in the review for the HSE, the review presented here is based on the findings from 61 studies, which focused specifically on the impact of post-registration nursing and midwifery education programmes on practice from a nurse, midwife, patient, carer, education and health service perspective. The remaining 36 studies focused on other aspects of programme evaluations such as educational methods, clinical practice assessments, training needs analysis, purchasing of education, and reasons, benefits and constraints of undertaking post-registration programmes. Included studies The majority of studies were undertaken in the UK, Australia and the USA, probably related to the English language bias of the databases searched. These ranged from studies of evaluations of single modules, specialist courses, generic courses, to evaluation of masters and doctoral programmes. Two authors, Brooker (psychiatric nursing) and Pelletier (generic programmes), featured prominently in the literature, with both of them having evaluated programmes over an extended time period. Papers on the impact of doctoral education are in its infancy. No evaluations were located which examined intellectual disabilities nursing programmes, or the cost-benefit implications ( value for money ) of programmes (Table 2).

3 66 H. Gijbels et al. / Nurse Education in Practice 10 (2010) Table 2 Details of included studies (N = 61). Countries represented Australia 8 Canada 2 Ireland 2 New Zealand 2 USA 8 UK 39 Focus of study Mental health 19 Masters 10 Generic 10 Doctorate/Ph.D. 5 Community 5 General nursing 3 Critical care 3 Gerontology 2 Neonatal/paediatrics 2 Accident and emergency 1 Midwifery 1 Researchers with multiple Brooker (mental health) between 1990 and 2003 publications Pelletier (generic) between 1994 and 2005 Research design Description Quantitative 30 (49%) Surveys, postal questionnaires Response rates ranging from 33% to 93% Numerical responses ranging from 5 to 990 Longitudinal nature Quasi-experimental studies with pre- and post-test measures of students, patients or carers, with control groups, and with followups at various intervals, up to 12 months post-intervention Qualitative 12 (19%) Phenomenology or grounded theory Interviews individual or focus group Samples size from 5 to 175 in 24 focus groups Mixed methods 18 (30%) Questionnaires and interviews Impact of post-registration at a national level Systematic review 1 (12%) Barr et al. (2005) Just under half of the studies had a quantitative research design. Most of these were descriptive, some longitudinal (Pelletier et al., 1994, 1998a,b,c, 2003, 2005; Whyte et al., 2000; Gournay et al., 2000), with the remaining ones having a quasi-experimental design, some with pre- and post-test measures of students, patients or carers, with control groups, and with follow-ups at various intervals, up to 12 months post-intervention (Brooker, 1990; Brooker and Butterworth, 1993; Brooker et al., 1992, 1994, 2002, 2003; Carpenter et al., 2006; Lancashire et al., 1997). These latter studies, of mental health programmes, were the most rigorous. The studies by Brooker et al. (1994), Lancashire et al. (1997), and Carpenter et al. (2006) were the only studies in which patient measures were taken to evaluate the impact of post-registration education. A mixed methodology was used in 18 studies and one of these evaluated programmes at a national level (Nolan et al., 2000). There were 12 qualitative studies adopting mainly phenomenological or grounded theory designs. Most studies represented either type 5 or type 4 evidence, with two studies (Barr et al., 2005; Carpenter et al., 2006) representing type 2 evidence (Table 2). The studies were, on the whole, devoid of any conceptual framework, with most evaluating a particular programme, or aspects of a programme, for a particular group of students, undertaken mainly within a third level institution, often providing very little information on details of the programme or the research design. The evidence was fragmented and did not offer a comprehensive coherent picture. Findings Using Barr s et al. (1999) evaluative framework, an attempt is made here to provide a comprehensive and coherent picture of the impact of post-registration education, based on the available published evidence. Where studies evaluated more than one level, the highest level evaluated is included on the table (Table 3). Level 1: This evaluates students views of their learning experiences and satisfaction with their training and education. There is evidence that students and, in some studies managers, were satisfied with their programmes in terms of relevance, support Table 3 Research design and types of evidence (N = 61). Barr s Frame-work (61) Types of evidence (61) Focused on: Level % 1. Learners reaction Level 2 2 3% 2. Change in attitudes and perceptions Level % 3. Acquisition of knowledge and skills Level 4 3 5% 4. Changes in behaviour Level 5 3 5% 5. Changes in organizational practices Level 6 3 5% 6. Benefits to patients and carers Evidence of: Type 1 0 0% 1. Systematic review of well designed random controlled trial Type 2 2 3% 2. At least one well designed controlled trial without randomization Type 3 0 0% 3. Published well designed trials without randomization Type 4 5 7% 4. Well designed non-experimental studies Type % 5. Opinions of respected authorities, descriptive studies, reports

4 H. Gijbels et al. / Nurse Education in Practice 10 (2010) received, and career opportunities available to them. Selected examples of this comes from evaluations of single modules (Williams et al., 1999; Mariano, 2002), generic post-registration (McCarthy and Evans, 2003) and masters programmes (Whyte et al., 2000; Spencer, 2006), specialist programmes (Gauntlett, 2005; Happell, 2005; Rassool and Oyefeso, 2007) and interprofessional programmes (Brown, 2000; Carpenter et al., 2006; Clifton et al., 2006). There was evidence of dissatisfaction with one programme (Nicolson et al., 2005). The mainly type 4 and type 5 evidence demonstrates that students generally express satisfaction with individual post-registration modules or programmes, with the evidence mainly relying on self-reports through questionnaires and interviews. Level 2: This evaluates the students changes in attitudes and perceptions towards patients and carers, their needs, circumstances, care and treatment. Programmes appear to have a positive impact on attitudes and perceptions such as increased confidence and assertiveness, ability to share knowledge, development of research skills, and leading discussions (Nicolson et al., 2005; Ellis and Nolan, 2005), improved attitudes towards clients (Lam et al., 1993; Brooker et al., 2003; Forrest et al., 2004) better understanding of other healthcare professionals (Clifton et al., 2006), and increased job satisfaction and self-esteem (Pelletier et al., 1994). However, one study found that attitudes did not always change (Brooker and Butterworth, 1993), although the authors point out that the students attitude may already have been positive. Carpenter et al. (2006) found little evidence of a change in professional stereotyping amongst students who had completed an interprofessional community mental health course. The evidence here too is derived mainly from studies of type 4 and type 5 evidence, through questionnaires and semi-structured interviews, and one study type 2 evidence (pre- and post-course evaluations from immediate to a maximum of 24 months). Level 3: This evaluates the acquisition of knowledge and skills as regards concepts, procedures and principles of working with specific patient groups, of critical thinking, problem solving, intervention and team working skills. There is evidence from a wide area of programmes which indicate the impact on students acquiring appropriate and technical, interpersonal, professional, cognitive and academic knowledge and skills. Evidence comes from evaluation of single modules (Jordan et al., 1999; Williams et al., 1999; Rains and Carroll, 2000; Mariano, 2002), specialist courses (Lam et al., 1993; Pullon and Fry, 2005; Wyatt, 2007), generic post-registration programmes (Nolan et al., 1995; Spence, 2004) and interprofessional programmes (Carpenter et al., 2006). One study indicated that the majority of managers were pleased with the competencies and skills of nurses who had completed a course (Endacott et al., 2000). However, Brooker (1990) found that neither students nor managers identified skill improvement, whilst Parsons and Barker (2000) reported that managers felt that students overestimated their level of skill acquisition. The evidence here too is based primarily on type 4 and type 5 studies. Most of the evidence was based on data gathered either shortly before or after the completion of programmes and it cannot be assumed that the acquired knowledge and skills were sustained over time. Level 4: This evaluates the students implementation of their learning, as a result of changes in attitudes and perceptions, and acquired knowledge and skills. There is evidence that students implement at least some aspects of their learning. Changes have been reported in relation to practice development initiatives and interventions (Forrest et al., 2004; Happell, 2005; Gauntlett, 2005; Carpenter et al., 2006), providing improved care for families (Brooker et al., 1992; Brooker and Butterworth, 1993) and using assessment skills (Brooker et al., 2003). However, a number of studies (e.g. Brennan and Gamble, 1997) identified that students encountered difficulties in implementing their skills. Other changes have been reported regarding using research skills, teaching skills, evidence based practice skills (Pelletier et al., 1998b; Hardwick and Jordan, 2002; McCarthy and Evans, 2003; Nolan et al., 2000), and the impact of nurses decision making skills (Considine et al., 2001). From an interprofessional perspective, improved collaborative working has been documented (Miller, 2004; Pullon and Fry, 2005), as has a generic improvement in job performance (Brown, 2000). Finally, doctoral prepared nurses have demonstrated enhanced patient care through research activities with staff (Berger et al., 1999), enhanced professional credibility and clinical leadership skills (Ellis, 2006). The changes highlighted reflect the nurses and midwives personal and professional developments, although some studies (Brooker et al., 2003; Carpenter et al., 2006) provide evidence of positive patients and carers outcomes. The evidence has come mainly through self-reports (type 4 and type 5 studies) with studies also drawing on managers, lecturers, service users and carers reports, and on independent ratings, whilst a minority of studies also used pre- and post-test measures, including those of patients and carers. Level 5: This evaluates the wider changes in organisational health care practice and delivery. Evidence here comes from one systematic review (type 2 evidence) of 107 studies of interprofessional health and social care education (IPE) (Barr et al., 2005). Evaluations of hospital and community based IPE were evenly balanced, with more studies focusing on long term than acute conditions. Participants in these studies were mostly nurses. The reported outcomes emphasised the further development of collaboration and the improvement of services. Level 6: This evaluates the benefits to and improvements in the health and well being of patients and carers. Evidence of benefits for patients and carers have been reported on in studies on mental health care, for example patients and carers improvements in knowledge (Brooker et al., 1992), reductions in patient symptoms, days spent in hospital, improvements in patients social functioning (Brooker et al., 1994; Lancashire et al., 1997), and improvements in patients social functioning, life satisfaction, life skills, and patient and carer satisfaction with nurses knowledge, skills and personal qualities (Carpenter et al., 2006). These type 2 evidence studies were only found in the area of mental health. Discussion Although the diversity in nursing and midwifery education systems across countries did not make for easy interpretation and understanding of the findings of this review, the studies presented here demonstrated that a great deal of work has been undertaken internationally to evaluate the impact on practice of post-registration nursing and midwifery education. The findings are consistent across different settings and contexts offering valuable information to inform the further development of programmes and to provide guidance for further research activities in this area. As has been shown, the impact of post-registration programmes has been evaluated mainly from the student perspective, with the perspectives of course leaders, service providers, and the overall heath service impact reflected only in a minority of studies. There were only three studies, which evaluated patient and carer outcomes. Although these outcomes were positive, Carpenter et al. (2006) in their study pointed out that these outcomes may not necessarily be attributable to the programmes. Nolan et al. (2000) found that both nurses and nurse managers agreed that Continuing Professional Education is essential. It is clear from the review presented here that students benefit from post-registration programmes in relation to changes in attitudes,

5 68 H. Gijbels et al. / Nurse Education in Practice 10 (2010) perceptions, and knowledge and skill acquisition, and applying these newly acquired knowledge and skills. However, these benefits relate mainly to the students personal and professional developments and achievements, rather than to practice developments, organisational changes, and patient outcomes. Indeed, Hardwick and Jordan (2002) concluded that the programmes they evaluated had only an indirect impact on care and patient outcomes. The evidence came mainly from studies in the area of general and psychiatric nursing, with the most rigorous and sustained studies undertaken in the area of mental health (e.g. the studies by Brooker; Carpenter et al., 2006). There was little research evidence of the impact of public health nursing, midwifery, and doctoral education. There was no evidence at all of the impact of intellectual disability nursing programmes, and neither was there any evidence evaluating whether post-registration education nursing and midwifery programmes offer value for money. Study designs were on the whole descriptive and retrospective in nature (types 4 and 5), adopting either postal questionnaires or semi-structured interviews as data collection methods, with types 2 and 3 study designs in a clear minority. Sample sizes differed, with evidence of large samples in national programme evaluations. The retrospective nature however of most of the studies made it difficult to link the impact to the students post-registration learning. It is evident that types 1 and 2 evaluative studies are needed, which critically analyse the impact of educational programmes on clinical practice and the quality of care provided, incorporating patient outcomes, thereby addressing the substantive and methodological limitations of most of the studies presented in this paper. However, tensions have been highlighted by Wood (1998) and Clifton et al. (2006) between what is considered to be the recommended methodological approach the randomised control trial (RCT) and the practical realities of evaluating programmes, with the difficulties of incorporating a control group, and the difficulties in controlling the many variables, for example the individual nurses being studied, their practice area, their patient caseload and the programme undertaken. The limited research evidence available indicated that nurses have found IPE highly relevant to their job performance and career progression. In that context, Carpenter s et al. (2006) study design represented an excellent example to replicate in any future study. Their study was carried out by an independent external research team, conducted over five years, tracking three cohorts of students through two years of an interprofessional (IPE) mental health programme, and investigating the outcomes for two successive groups of service users. Their comprehensive, longitudinal evaluation provided evidence of the positive outcomes of interprofessional, postqualifying education at the various levels of learners reactions, knowledge and skills, implementation of learning and of benefits to users and carers. Conclusion Barr s et al. (1999) framework provided a useful structure in which to organise and analyse this systematic review. There is little evidence of the impact of post-registration on practice. However, a comprehensive picture of the evaluation of postregistration programmes emerged along the continuum from individual modules to generic and specialist programmes to a national review. The review provides a broad rather than an in-depth evaluation. There is scope and merit to undertake further systematic reviews, which focus on the evaluation of specific programmes, such as the one undertaken by Brooker and Brabban (2004). To further advance our understanding of the value and impact of post-registration education, systematic evaluation frameworks, such as those developed by for example Barr et al. (1999), Brooker and Curran (2005) and Carpenter et al. (2006), should be adopted to guide programme development, implementation, monitoring and evaluation. Further studies, especially those of type 1 and type 2 evidence, are required to evaluate the impact on organisational and service delivery changes, and patient and carer outcomes. There is a dearth of literature which evaluates midwifery, intellectual disability nursing, and doctoral education programmes which indicates a need for further programme evaluations in these areas. There are many studies which demonstrate benefits at various levels. However, it can be concluded that the impact of post-registration nursing and midwifery education on practice has yet to be fully explored and realised through a more systematic and coherent programme evaluation approach. Acknowledgements The authors would like thank the Review Group for commissioning the team to undertake the systematic review, Claire O Brien, nursing subject librarian at the Brookfield Health Sciences library in University College Cork for her guidance and advice on the search strategy, and Brenda Lehane, Research Assistant, for assisting in the initial search and assessment of the appropriateness of the search results. This review was supported by a grant from the Post-registration Nursing and Midwifery Education Review Group, Health Service Executive, Ireland. References Barr, H., Freeth, D., Hammick, M., Koppel, I., Reeves, S., Evaluating Inter Professional Education: A United Kingdom Review for Health and Social Care. British Educational Research Association/Centre for the Advancement of Interprofessional Education, London. Barr, H., Freeth, D., Hammick, M., Koppel, I., Reeves, S. (Eds.), Effective Interprofessional Education: Argument, Assumption and Evidence. Blackwell, Oxford. Berger, A., Eilers, J., Heermann, J., Warren, J., Franco, T., Triolo, P., Stateof-theart patient care. The impact of doctorally prepared clinical nurses. Clinical Nurse Specialist 13 (5), Brennan, G., Gamble, C., Schizophrenia, family work and clinical practice. Mental Health Nursing 17, Brooker, C., A six-year follow-up study of nurses attending a course in community psychiatric nursing. In: Brooker, C. 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