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As our clients demand greater and greater accountability, we as professionals are increasingly being challenged to meet rising expectations. This is translating into an emphasis across professions and borders on the continual improvement of practice by individuals, employers, regulatory bodies, and governments. This editorial sets out to describe the changes to the nursing re-registration process happening in both Canada and the UK, and the increased emphasis on lifelong, self directed learning as the mechanism for ensuring continued competence in practice. In particular, we will describe how resources such as Evidence-Based Nursing and the Cochrane Library can help with the process of continuing professional development (CPD) and registration.
Most nurses undergo a basic training that lasts for 3 or 4 years. This training equips them with basic competencies and prepares them for a 30 or 40 year career in which most of their learning will take place. Historically, payment of an annual fee was the only requirement for maintaining registration as a nurse, but there have long been concerns that this is no safeguard against outdated knowledge and an unthinking approach to practice. Whereas CPD was once viewed as a desirable option, it is now a prerequisite for periodic re-registration.
The Ontario experience
In Canada, each province regulates nursing independently under different legislation, although there is considerable interprovincial communication about issues of concern to all, such as labour mobility and cross provincial registration. In Ontario, responsive legislation in the form of the Ontario-specific Regulated Health Professions' Act (1991) requires that all 23 of the health professions create programmes that “assure the quality of the practice of the profession and promote continuing competence among the members.”1 The College of Nurses of Ontario (CNO), the provincial regulatory body for registered nurses and registered practical nurses, has designed and begun to implement a programme that requires the 142 000 nurses to participate annually in a process of reflection. Reflecting on practice means thinking about clinical experiences and asking questions such as, “how might we do that better?” And also, “that worked really well—let's find out why!”
Ontario's “reflective practice” approach guides nurses through a series of 5 steps: (1) performing a self assessment of their practice; (2) obtaining peer feedback on their practice (nurses choose the peer and determine how best to obtain feedback); (3) creating a learning plan; (4) implementing the learning plan; and (5) evaluating what they have learnt and its impact on their practice. Nurses are expected to use the results of their reflective self assessment and peer feedback to identify key learning projects that will enhance their practice over the year. These projects must be relevant to the nurse's practice and related to her learning goals.
The strategies that are used to implement the project may vary depending upon nurses' learning styles, their personal resources, and the availability of relevant learning activities. Learning strategies are not dictated; rather, Ontario has taken the view that nurses know best what they need to know and how to get it. There are no requisite numbers of hours, courses, or units. Whether nurses involve a colleague, turn to journals, videos, books, or take courses is not important to CNO; that nurses have taken the initiative, completed a learning project, and attempted to enhance their practice is.
To facilitate nurses' participation in the reflective practice process, CNO has created several tools. A self assessment questionnaire allows nurses to identify their strengths, weaknesses, and possible learning opportunities. This self assessment tool is based on the professional standards of practice for registered nurses and registered practical nurses in Ontario and focuses on communication, leadership, critical thinking and job knowledge, and standards and legislation. The questionnaire asks nurses to rate their performance against statements such as “I review research literature and assess what it means for my practice and work setting,” and “I base my decisions on current accepted research and standards of practice.” Another tool developed as part of the Ontario project is a professional profile or portfolio, which guides nurses through a reflective self assessment of their past experience as well as their current practice. This enables nurses to identify trends in their experiences and practice, and to appreciate accomplishments. It is envisaged that working through the focused, reflective process will help nurses to develop self awareness and that the document or portfolio will be useful for illustrating their experience to others, such as employers. Each tool includes a guide for obtaining and providing peer feedback and creating a learning plan.
Regardless of the approach a nurse chooses, each nurse is expected to have participated in the process and a statutory committee exists to supportively monitor participation in the programme. Nurses are expected to complete each of the 5 requirements and keep the results for their own records. Each year they are required to provide a declaration that they have complied with the requirements and maintained their records accordingly. 1998 marked the first year of implementation of the programme and the first time nurses were required to declare their participation. A random audit process will occur in the near future and provide a means to evaluate the tools, process, and outcomes of the programme, as well as to monitor nurses' participation in the programme.
In Canada, the reflective practice process as used by the CNO is breaking new ground. CNO was the first nursing organisation to adopt such an approach for continuing competence. Historically, this type of programme has not existed in the Canadian nursing arena, nor has it existed in the other health professions in Ontario. CNO has provided leadership and support as professional organisations, both national and international, have grappled with the area of continuing competence.
The approach is also new for nurses. They are now expected to undertake activities such as self assessment and peer feedback, which they may be initially uncomfortable with. Nurses, however, are beginning to embrace these challenging activities, and the feedback from nurses of various ages and experience levels is that they have learnt a great deal about themselves on both personal and professional levels. They are feeling more connected with their peers as a result of engaging in discussions about their practice. Nurses are also seeing how their learning can be integrated into their practice. The first year of implementation has been quite successful, with more than 75% of nurses participating in reflective practice.
Through this process, nurses are all learning, and as they gain experience with the process, they will become more comfortable questioning their practice, thoughtfully planning their learning, and applying their new learning to their practice. Their experiences of reflecting and questioning will also help them to become more discriminating about the information and resources they access. Reflecting on practice is part of evidence-based nursing and is one way to continually improve practice.
The UK experience
In the UK, the regulatory body for nursing is the UK Central Council for Nursing, Midwifery, and Health Visiting (UKCC), which superceded the General Nursing Council in 1979. The council exists primarily to protect the public by establishing and upholding professional and educational standards. The council currently maintains the register of qualified professionals, although this will change in the near future.
The UKCC has been re-shaping pre-registration and continuing nurse education for more than 10 years and its framework for post-registration education and practice (PREP) identified 4 major changes to maintaining registration2:
Completion of a notification of practice form every 3 years, or if the nurse changes her area of practice
Completion of a minimum of 5 days study or learning activity every 3 years
Maintenance of a personal professional profile that details an individual's professional development
Completion of a return to practice programme if nurses have been out of practice for 5 years or more.
Each nurse is responsible for determining her own learning needs, constructing opportunities for 35 hours of learning activity to fill those needs, and documenting the learning in a professional profile. The 35 hours of study or other learning activity need not be in the form of formal course work or study days; the reflection on practice and self directed learning should be in a format that suits the individual. The professional profile is, in essence, a reflective diary that not only documents planned learning and learning from practice but also contributes to the process of reflection. All practitioners in the UK will be expected to meet PREP requirements by April 2001, and the UKCC is currently establishing a formal audit system to monitor whether requirements are met.
How can evidence-based resources help?
Clearly, simply reading a journal and documenting how long it took you to read it is insufficient; however, evidence-based journals can help you to fulfil your registration requirements in various creative ways. Firstly, they can act as an aid to your reflection. Evidence-Based Nursing only abstracts the highest quality, most reliable research, and therefore you know that the information contained in the abstracts is worth seriously considering in relation to your practice. The commentaries written by nurses should also help you to consider what the research means for your practice. You may then be prompted to discuss the research with colleagues, seek further information, learn a new skill, or change practice. This process is clearly worthy of documentation.
Secondly, if you have already reflected on your practice and identified elements that you would like to develop, the first place to look for relevant and reliable research is the evidence-based journals. As a first step, you could look for a pre-appraised and distilled systematic review of all the available research in the area; Evidence-Based Nursing seeks to abstract systematic reviews, such as those undertaken by the Cochrane Collaboration, whenever they contain an important message for nurses. In the absence of a pre-appraised and abstracted review, practitioners should turn to the Cochrane Library for the full text of a relevant systematic review, and failing that, journals such as Evidence-Based Nursing for pre-appraised and abstracted primary research.
Thirdly, the editorial content of Evidence-Based Nursing provides much useful food for thought and information for action. The Notebook can help you to develop core skills for practice development such as asking answerable questions3 and searching for answers.4 By reading the Implementation Forum articles, you can learn which methods of CPD are effective5, 6 and learn from the experiences of others who have successfully changed practice.7
Fourthly, many of our commentators have expressed how the process of engaging with a piece of research and writing a clinical commentary to accompany the abstract has helped them to focus on their practice, learn about a piece of research in detail, and consider how the research relates to them. You might therefore like to consider becoming a commentator—simply fill in the form enclosed in the journal. If you document your reflection and learning activities, describe what you have gained from them, and how it relates to your practice, Evidence-Based Nursing can be a valuable aid to your re-registration.
Finally, this article would not be complete without consideration of those learning strategies that have been evaluated for their impact on practice. Waddell reviewed 34 studies that measured the impact of continuing education on actual or reported practice.8 She concluded that continuing education does lead to positive changes in nursing practice; the magnitude of the effect is, however, unclear. Thomson, in her Evidence-Based Nursing editorial, provided an excellent “review of reviews” and reminded us that strategies such as didactic lectures are much less effective ways of ensuring professional behaviour change than interactive workshops, and that reading alone is also likely to have little impact.5 However, used creatively, and preferably with colleagues, Evidence-Based Nursing can help you to reflect on your practice and find reliable and digestible research evidence relevant to practice, wherever in the world you live. This editorial has described CPD in one Canadian province and in the UK. We invite letters or editorials describing CPD in other countries and additional ways that evidence-based resources can facilitate this process.