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Structural barriers and supports for nurses’ continuing professional development in acute care : a scoping… Cehic, Irma 2018-08

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Running Head: CONTINUING PROFESSIONAL DEVELOPMENT    Structural Barriers and Supports for Nurses’  Continuing Professional Development in Acute Care - A Scoping Review By:  IRMA CEHIC BScN, The University of Ottawa, 2011  A SPAR PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE  REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING   in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES    (School of Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA  Vancouver  August 2018    © Irma Cehic, 2018   CONTINUING PROFESSIONAL DEVELOPMENT  2 Abstract  Continuing professional development (CPD) is an ongoing obligation nurses have to the public. It is how nurses maintain professional and practice standards, but also, it is a means for nurses to develop their careers in nursing education, leadership, practice and research. By using a scoping review methodology, I sought to answer what are the structural barriers and supports that exist for nurses in meeting their CPD obligations in acute care settings. Three theoretical frameworks (adult learning theory, complex adaptive systems theory and relational inquiry) were used to guide my critical analysis, discussion, implications, and recommendations. Amongst the findings, fifty-one sources were used to inform five themes: sense of community; a vision and mission from leadership and management; resource accessibility; commitment to learner-centered foci; and optimized workplace environments. I discuss implications for nursing education, leadership, practice and research domains, as well as recommendations for stakeholder at all levels.  Keywords: continuing education, professional development, work-based learning, scoping review, nursing, acute care, barrier, support               CONTINUING PROFESSIONAL DEVELOPMENT  3       Abstract                 2             Chapter One: Introduction               7 Professional Development                                                   9                                 Assumptions                                                           10   Significance                                                       11   Impact of Issue in Nursing Practice and Health Care.                                   11   Potential for Advancing the Nursing Profession.                                                14 Purpose                       16 Research Question.                  16              Chapter Two: Scoping Review           16   Theoretical Frameworks                         16     Adult learning theory.                         16  Relational inquiry.                          18  Complex adaptive systems.                            19  Methodology                               21  Search strategy.                         23   Database search.                 23    Inclusion criteria.                    27  Exclusion criteria.                 28  Snowballing and hand selection of grey literature search.            28  Findings                                   29   Theme summaries.                              30   Sense of community.                                 30   CONTINUING PROFESSIONAL DEVELOPMENT  4  Vision and mission from leadership and management.            30    Resource accessibility.                31   Commitment to learner-centered foci.              32   Optimized workplace environments.                 32    Chapter Three: Critical Analysis            33   Analysis of Findings                  33      Sense of community.                 34   Vision and mission from leadership and management.                        39   Resource accessibility.                46   Commitment to learner-centered foci.              50   Optimized workplace environments.               54  Discussion                    58   Limitations                   59    Methodological limits.                59    Content limits.                 60      Chapter Four: Implications and Recommendations           61    Implications                       61   Nursing Education.                             61   Nursing Leadership.                 64             Nursing Clinical Practice.                 67    Nursing Research.                             70   Recommendations                                         71      Macro level.                                                   72   CONTINUING PROFESSIONAL DEVELOPMENT  5  Meso level.                                         76   Micro level.                                         81   Conclusion                                                    82            References               83             Appendix                 101                           CONTINUING PROFESSIONAL DEVELOPMENT  6        "Were there none who were discontented with what they have,  the world would never reach anything better.” - Florence Nightingale                    CONTINUING PROFESSIONAL DEVELOPMENT  7 Scholarly Practice Advancement Research Project: Structural Barriers and Supports for Nurses’  Continuing Professional Development in Acute Care - A Scoping Review          Chapter One: Introduction  The intention of this Scholarly Practice Advancement Research (SPAR) project is to focus my research and critique on an issue within the nursing discipline to help advance nursing practice and health care (The University of British Columbia [UBC], 2017). My particular interest in nursing lies in the domain of education; however, through my coursework experience I have learned that this domain heavily overlaps with those of health policy and leadership. In Canada’s contemporary health care system, I have found nursing education (i.e.: professional development) keeps me resilient, engaged, and accountable in my professional practice; a few key reasons for why I pursued this project and graduate studies altogether. Having worked in acute care organizations in both Ontario and British Columbia (BC), I have observed both direct and indirect supports and barriers that have impacted my personal capacity in engaging in professional development (PD) activities. In order to have a wider perspective of these supports and barriers, I am curious to explore the structural level influences that end up impacting nurses’ participation in these activities. I aim to incorporate these various domains of nursing into my SPAR project to help advance the practice of nursing.  As novice or seasoned nurses, we largely look to our nursing leadership for coaching, mentorship, and role modeling in order to access opportunities to provide, improve, and assure quality care. Amongst the various acute care organizations in BC, this sort of leadership can vary in appearance, accessibility and scope. This does not mean that nurses are incapable of taking initiative to foster their own PD. In fact, not only are they capable of acknowledging areas for improvement, their regulatory bodies mandate them to do so. BC’s regulatory college for nurses,  CONTINUING PROFESSIONAL DEVELOPMENT  8 the College of Registered Nurses of British Columbia (CRNBC, 2017), has identified PD activities as necessary to guide a nurse in meeting standards of practice. However, the contemporary situations in our health care system constrain nurses’ agencies to authentically and actively engage in PD activities (Byres, 2018; Henderson & Eaton, 2013; McWilliam, 2007). In acute care settings, nurses work within an interprofessional context and varied levels of experience. I believe that under optimized circumstances, organizations can leverage the experiences and capacities of their health human resources (which largely includes nurses) if these said organizations could provide the means for their staff’s PD. Optimizing PD has large potential for creating endless opportunities for innovation and practice improvements. This ultimately boils down to enhanced patient care (McCormack & Slater, 2006). Unfortunately, a liberal welfare state like Canada has public policies that impact health care organizations to have minimal involvement and accountability in the resources nurses require for their training and education across the career trajectory (Bryant, 2010).    Many organizations have incorporated strategies that support nurses in meeting their professional competencies, but others still have many barriers to overcome in nurturing continued education opportunities (Coventry, Maslin-Prothero, & Smith, 2015; Katsikitis et al., 2013; Niemeyer, 2018). There are factors that are considered to be either modifiable or intractable towards the constraint of nurses’ professional capabilities within acute care organizations. Nurses and other health care professionals are held accountable for the care they provide for their patients, and the same standard should be applied to acute care organizations and employers. Their ‘clout’ should be used to advocate for the needs of its workers. In my graduate studies, I have and continue to learn that the nursing profession faces many challenges, and nurses’ key professional capacities are impeded by many systemic policies. By using a  CONTINUING PROFESSIONAL DEVELOPMENT  9 scoping review methodology for this SPAR project, I will explore the complex variables that affect nurses’ abilities to engage in PD. Researching this phenomenon will help inform and highlight implications, as well as offer recommendations for key stakeholders to unlock the doors for advancing the nursing profession and ultimately, health care. Professional Development   For the last century, BC has socially and legally acknowledged registered nurses (RNs) as regulated health professionals. In 2005, the Nurses (Registered) Act was repealed and RNs continued to be acknowledged as self-regulated health professionals under the BC Health Professions Act (Government of British Columbia, n.d.b). This latter recognition comes with the expectation and requirement that nurses are lifelong learners, self-assess their practice, work within their regulated scope, and meet professional and practice standards – all components of an overall PD plan (BC Health Regulators, 2016; CRNBC, 2018a).    In addition to these legislative requirements, there are regulatory mandates that are governed by CRNBC. Registrants must undergo continuous quality assurance activities and policies set by the college. Nurses complete an annual self-directed PD plan, and an additional plan informed by their peers’ appraisals every five years (CRNBC, 2018b). BC’s regulatory body also provides registrants with access to CRNBC’s practice supports such as their Quality Assurance portfolio and learning web modules to foster nurses’ engagement in reflective practice. Furthermore, RN’s national professional voice, the Canadian Nurses Association (CNA, 2018b) and the CRNBC both offer nurses acceptable suggestions for PD activities; such as self-directed informal and formal learning, research, workshops, conferences, in-services, and more.             In the literature, the term professional development is also synonymous with terms like continuous education (Nursing Education Council of British Columbia [NECBC], 2008),  CONTINUING PROFESSIONAL DEVELOPMENT  10 continuing competence (CRNBC, 2018c), learning plan (College of Nurses of Ontario, 2018), certification, (Cherry & Mitchell, 2014), or simply education (Kol, İlaslan, & Turkay, 2017). Nurses’ PD can advance or maintain their professional competencies to either stay or advance in their current workplace environment, or train towards working in a new specialty or domain (Arthurs et al., 2018; Johnson, Billingsley, Crichlow, & Ferrell, 2011). In this SPAR project, I conceptualize PD to include work towards the maintenance or advancement of nurses’ standards of practice: whether it be professional or practice standards (CRNBC, 2018a). Holloway, Arcus and Orsborn (2018) use the term continuous professional development (CPD) in their research study. They say, “the requirement for nurses to participate in CPD is underpinned by the belief that engaging in ongoing professional learning is an ethical act, an aspect of a duty to care…is each nurse’s responsibility and reflects civic professionalism,” (p. 8). When nurses’ educational endeavors are situated in the context of their profession, I conceptualize this pursuit to be an ongoing journey; as such, I use the term CPD throughout1 this research paper.  Assumptions  I believe that legislative and regulatory mandates are insufficient for nurses to actualize CPD in practice. At the organizational level, there need to be supports in place for nurses to have a choice and voice in which CPD activities are relevant for them to provide quality patient care. In this analysis, I conceptualize organizational support of CPD akin to Coventry and colleagues’ (2015) description in their integrative review:  Literature associates organizational support of [continuous professional development (CPD)] with performance appraisal, training needs analysis, personal                                                         1 While I use CPD to describe nurses’ ongoing learning and development in relation to their professional contexts, at times, I will use the term PD to describe individual activity along nurses’ CPD journeys.   CONTINUING PROFESSIONAL DEVELOPMENT  11 professional development plans, structured mentoring or coaching, identification of career paths, paid study leave and support by clinical nurse managers and organizational clinical educators… commitment to CPD is a shared relationship between individual nurses and organizations and integral to the nursing profession. (p. 2716)  Since CPD is understood as an ongoing learning journey, organizations should provide nurses with continuous resources to promote education and maintenance of competencies for quality and safe patient care.    I also assume the current sense of accountability to nurses at the structural level is limited due to the sheer volume of nurses as well as the financial costs in coordinating CPD. Understandably, cost constraints influence decisions and are often part of discussions regarding health care systems. There seems to be an implicit understanding that creating a workplace environment that supports CPD is not the organization’s business or interest; meaning nurses’ education is not prioritized by their employers. I also believe the way our current health care system is operationalized in terms of staffing, workload distribution, compensation, management, staff-mix, use of RN’s scope, and models of care, are a few of the many variables within the practice environment that encroach on an RN’s well-being, motivation, and capacity to seek CPD activities. Anecdotally, I have observed and experienced these variables to affect my colleagues and I. Nurses work so hard that it leads them to experience compassion fatigue, burnout and even attrition. I believe these latter issues in the nursing profession also impact RNs’ agencies to engage in CPD.  Significance  Impact of Issue in Nursing Practice and Health Care. There are numerous empirical  CONTINUING PROFESSIONAL DEVELOPMENT  12 and commissioned recommendations that indicate organizations should support a nurturing workplace environment, in order to provide optimal working conditions for nurses to provide quality patient care (Byres, 2018; RNAO, 2016). The issue of retaining nurses in their current workplaces is reflected in high turnover rates. This is true for new graduates, as well as those with experience. The available evidence links poor CPD supports with attrition from the nursing profession (Daouk-Öyry, Anouze, Otaki, Dumit, & Osman, 2014). Lack of support has been documented as ineffective compensation and education funding, inaccessible educational opportunities, unmanageable workload, negative organizational culture, inappropriate staff mix and staffing ratios, and much more (Bartelt et al., 2011; Coventry et al., 2015; Kol et al., 2017).  Oftentimes, the organizational role in supporting nurses’ CPD is not acknowledged by health care policy. For instance, the lack of career opportunities and organizational policies that neglect nurses’ work-life balance were identified as a huge cause for nursing shortages by the CNA (2001) almost twenty years ago. In BC, Byres (2018) found that, “many nurses and nursing leaders requested that a formal process be created that could be used to better determine the staffing model(s) to best meet the needs of the patient population being cared for” (p. 17), as well as a lack of availability of expert nursing advice and consultation. Perhaps, this observation suggests that the current state of clinical leadership in acute care facilities also needs to be reframed in order to better reflect the needs of nurses. There are several macro level forces that contribute to this narrow sense of organizational accountability, such as liberal individualism, managerialism and constrained resource allocation (Duncan, Thorne, & Rodney, 2015). The impact of a health organization’s sense of optional investment has serious repercussions for our incoming workforce facing increasingly complex patient caseloads. The repercussions are further perpetuated by fewer experienced colleagues available to act as mentors to junior nurses. In  CONTINUING PROFESSIONAL DEVELOPMENT  13 2016, the average age of a RN in BC was 44.5 years old (CNA, 2018a). It is apparent there is a plentiful supply of experienced mentors available in BC should the right conditions be fostered at the structural levels for use of such a precious resource. When taking all this into account, a critical review of the supports and barriers for nurses meeting their CPD requirements is timely and necessitates exploration as to what is and is not working in organizations for nurses to engage in CPD.   Lastly, our contemporary nursing workforce in Canada continues to experience a widening theory-practice gap upon their entry to practice (Del Bueno, 2005; Hussein & Osuji, 2017). “The inability of clinical research to be transferred into practice is often referred to as the theory-practice gap,” (Peck, Lester, Hinshaw, Stiles, & Dingman, 2009, p. 99). Corlett (2000) defined it as a mismatch between nursing theory taught in the classroom and actual nursing practice. Perhaps theory is not being exercised to its fullest capacity in practice due to how nursing is practiced. Structural barriers can diminish CPD in the workplace environment, and limit the, “theory development as a practical activity of inquiry, to cultivate situation-producing theory, and ultimately to enhance our theoretical practice,” (Doane & Varcoe, 2005, p. 89). Although the discussion regarding the theory-practice gap in nursing warrants a separate analysis, there is room to explore if the systemic constraints of nurses’ CPD may further separate theory and practice amongst the nursing professions. In Florida, performance measurement data showed only “35% of inexperienced RNs meet entry-level performance expectations” (Tyrna, Giannuzzi, & Guthrie, 2013, p. 173). The consequences of unprepared nursing graduates compounded with insufficient clinical supports and CPD opportunities for current registrants alike, poses a risk in limiting the potential for the influx of nurses to provide safe, effective and evidence-based care (Neimeyer, 2018).    CONTINUING PROFESSIONAL DEVELOPMENT  14  Potential for Advancing the Nursing Profession. Current hospital practice environments increasingly employ overworked, burnt out, and undervalued nurses (Byres, 2018; Compson, 2015). “Many nurses wished their work and contribution towards quality of care was better understood and recognized by their employers,” (Byres, p. 13). If nurses were to be given the agency and resources to access CPD opportunities, they would feel valued for their potential in providing better and top-quality patient care (Katsikitis et al., 2013). These Australian researchers suggest organizational conditions that support CPD can inspire empowerment and engagement in the nursing profession. Structural supports for nurses’ CPD can inspire their contributions to innovations within nursing sciences, in addition to nurses being able to identify local strategies in meeting population health needs (Thompson, Estabrooks, & Degner, 2006). If organizations support motivated nurses by giving them the right workplace conditions and resources, it could perhaps be a sustainable way of advancing health care in the acute care setting.   Currently, nurses barely have the resources and means to work with a focus and energy to get through their workday – let alone engage in CPD activities (CNA, 2018c). If more systemic supports for CPD were in place, more nurses would be positioned to work within their full scope; particularly, to critically engage with areas for practice improvements, research, and quality assurance (Kangasniemi, Vaismoradi, Jasper, & Turunen, 2013). In keeping with a relational lens, these supports for CPD are dependent on concurrently diminishing barriers of CPD like heavy workload, using personal time used for mandatory training, and a lack of financial compensation (Coventry et al., 2015). Findings from Henderson, Cooke, Creedy and Walker’s (2012) Australian study revealed that nursing students had limited capacity to “initiate dialogue around rationale for practices” (p. 301), and task completion was the focus of their usefulness in  CONTINUING PROFESSIONAL DEVELOPMENT  15 the clinical environment. I too have observed this task-oriented culture to be favoured in my places of work thus far in my professional career. There is insufficient allocated and protected time for nurses to engage in intra-professional collaboration about choices for plans of care, participation in unit and hospital affairs, or for even researching alternatives for ineffective or inefficient nursing care practices. These are all examples of how CPD is often sidelined because nursing practice is often being reduced to task completion (Feo & Kitson, 2016). With the current ‘reactive’ operationalization of our health care system (Duncan, Rodney, & Thorne, 2014), its value on task completion, and shorter length of stays, acute care organizations run the risk of their nurses placing little value on critical and reflective practice. If nurses had opportunities and encouragement from leadership to engage in both formal and informal CPD activities, perhaps their nursing practice could actually incorporate the professional standards framework set out by CRNBC (2018c). Nursing practice must be able to keep pace with the changing needs of BC’s population, and as such, be given the capacity they deserve to embody the nursing standards.  Henderson and colleagues’ above findings beg the question: Could the reason for their studied students’ observations be because nurses are constrained to work beyond their day to day nursing tasks? Simply put, there are critical implications for the nursing profession’s future if CPD is not seen as a priority by all.   It is clear that an analysis of the current barriers and supports nurses have for engaging in CPD requires an approach at all levels (individual, unit/ward level, organizational), as well as the health care system policies at both the provincial and national levels of government. Nurses certainly have a key role in seeking CPD opportunities. However, due to the reasons listed thus far, my scope will focus on the organizational level and how it can optimize its support for nurses in meeting their ongoing learning needs.   CONTINUING PROFESSIONAL DEVELOPMENT  16 Purpose  In this SPAR project, I will draw on concepts from several key theoretical lenses: relational inquiry, complex adaptive systems and adult learning theory. I will then use a scoping review methodology to gain a comprehensive understanding of the current state of PD supports and barriers for nurses in BC and its impacts on CPD activities at the individual, practice environment, management, and organization levels. This is because stakeholders at each level need to help one another stay accountable to one another in order to overcome challenges. Following my review, I will present a critical and mindful analysis of the literature’s inferences, assumptions and consequences (Elder & Paul, 2004). Although there have been a small number of international studies that examined a similar issue at the micro level such as individual nurses or workplace environments (Coventry et al., 2015; Katsikitis et al., 2013), I aim to bridge these levels with the impacts from overarching systemic levels in order to find common themes for organizational successes and failures in supporting nurses in meeting their CPD requirements. By casting a wide net through the use of such a methodology, I hope to uncover implications of this issue in various domains of nursing such as clinical practice, education, leadership and health policy in the Canadian health care setting.   Research Question. The research question is: What are the organizational barriers and supports that currently exist for nurses to meet their CPD obligations in acute care settings?     Chapter Two: Scoping Review  Theoretical Framework  As this is a complex problem impacted by many interrelated variables, I need to approach this research question with several overlapping theoretical perspectives.  Adult learning theory. The premise of my research question is based on the supposition  CONTINUING PROFESSIONAL DEVELOPMENT  17 that nurses are lifelong learners. The very conditions set out by our regulatory body and the constantly changing evidence that underpin our practice standards mandate nurses to continuously be up-to-date to provide safe and quality patient care. As such, perspectives from adult learning theory, also known as andragogy theory, fit to inform this expectation (as cited in DeYoung, 2014a). This theory has six key concepts: adults feel responsible for their own learning; their learning is self-directed due to a rather independent self-concept; their orientation to learning is based on its applicability to a task or problem; are ready to learn and willing to invest their time once their need to know is identified; adults use their experiences as a resource for learning; and their motivation for learning is primarily internally driven (DeYoung, 2014a; Jarvis, 2004; Knowles, 1985; Taylor & Kroth, 2009). With these principles in practice, in the right environment, motivated nurses would thrive in engaging with CPD. This is an especially valuable consideration in answering my research question because in order for nurses to meet their CPD obligations, they need to have the means to engage in a reflective practice in order to acknowledge their learning needs.   Furthermore, nurses need clinical leadership that welcome and facilitate nurses’ search for CPD activities. Knowles (1985), a pioneer of adult learning theory, clarified that being a self-directed learner does not mean learning independently or in isolation. Instead, he acknowledges the interdependency of peers, mentors and the greater context. He specifically appraised the American Nurses Association’s application of andragogy principles, applauding their acknowledgement of the need to access various modes of education to suit nurses’ differing learning needs. Education and learning still needs to be facilitated by the greater organizations in which nurses work, which is why the following theoretical framework is suitable to complement adult learning theory.  CONTINUING PROFESSIONAL DEVELOPMENT  18  Relational inquiry. Since several components of my research question are grounded in the philosophy of intentionality and conscious development of nursing knowledge and nursing practice, relational inquiry is the second theoretical framework that will guide my analysis. As Doane and Varcoe (2015) succinctly explain, “a relational inquiry process […] can be helpful in directly responding to the complex nature of nursing in contemporary health care,” (p. x). This theory can help examine this research question holistically through attentive and critical examination of all its influencing elements. A relational inquiry approach means taking intrapersonal, interpersonal, and contextual elements into heavy consideration, thus informing praxis that should occur at the individual, unit, organizational and macro levels. This multilevel approach for praxis is relevant for my research project that is focused at a structural level because it can highlight where and what are the power relations that affect continuing education and PD for nurses.   For this reason, I aim to use a critical lens within the context of relational inquiry. It can highlight the power dynamics that, unbeknownst to nurses, they encounter at the structural level for achieving their CPD duties. Critical theory is embedded within relational inquiry and facilitates awareness of the sociopolitical structures that benefit and hinder all involved stakeholders in my researched context (Doane & Varcoe, 2015). Alongside critical theory, a hermeneutic phenomenology perspective is another focus that is a core component of a relational inquiry. Hermeneutic phenomenology can help provide an interpretive analysis of people’s lived experiences. Although critical and hermeneutic phenomenology perspectives work well when used concurrently to guide praxis, my main focus will be to use the former lens to appreciate “how the social, political, historical, economics and linguistic features of the world are shaping lives and our nursing practice” (p. 55).    CONTINUING PROFESSIONAL DEVELOPMENT  19  Once again, one of my SPAR project purposes is to provide key stakeholders recommendations to inform decisions regarding CPD for nurses. For this reason, it will be imperative to use relational and critical frameworks so these stakeholders can steer these recommendations to ignite change towards nurses’ emancipation from the current structural constraints they experience in their CPD journey. I have situated this research question amongst an interplay of contemporary population needs, nurses’ needs, and organizations’ needs to name a few. Although the scope of this analysis will focus on how barriers and supports are enacted at the organizational level, praxis is required at all levels for effective change to occur.   Complex Adaptive Systems theory. Lastly, I will also use the complex adaptive systems (CAS) theory, one that is grounded within the subset of complexity science and chaos theory principles. CAS theory will complement the relational inquiry framework for this research question. Originally, complexity science was based in the physical, biological and mathematical sciences, in which “groups of living beings or organizations…can be described as CAS,” (Holden, 2005, p. 652). Complexity science describes behaviours and inputs of an alive system to produce self-organizing outputs in relation to their current status, past influences as well as their environments. Meanwhile, the chaos theory - another branch of complexity science – stipulates that any small change at one point in time will produce unpredictable results in the future (Holden). A CAS is both unpredictable and self-organizing, and this theory can help contextualize and expand the unique ways and conditions in which acute care settings operate.   It is imperative to understand how acute care settings function in order to answer my research question. Considering health care organizations are complex and dynamic systems, it is reasonable to describe them using a CAS theory. More specifically, it is helpful to acknowledge that acute care settings like a hospital can be a CAS because hospitals are constantly changing in  CONTINUING PROFESSIONAL DEVELOPMENT  20 order to adapt to their environment. A CAS has numerous stakeholders, its agents within it follow a certain set of unwritten rules, interact with one another whilst exchanging information, and it tries to self-organize in an aim to reach homeostasis (Holden, 2005; Paley, 2007). A unique feature of CASs is that it seldom reaches this equilibrium due to its dynamic nature. During this self-organization process, the “emergent structure of the CAS may influence behaviour of units comprising in it,” (Paley, 2007, p. 236). This means that based on the acute care setting’s position within the overall health care system, the interdependent interactions within a hospital influences the behaviours of its workers and management- a concept in CAS called downward causation (p. 236). Consequently, those in higher leadership positions must manage these organizations skillfully and accordingly.  Examining this research project using CAS theory can perhaps help inform how activities and/or decisions at the macro level (provincially, within BC’s policies and management of the health care system) impact the acute care facilities in ways that are both remote and unpredictable. “[CASs] are interactively complex, and the causes and effects are distant in time and space, making it difficult to predict the future,” (Tan & Tan, 2011, p. 369). For instance, conceptualizing an organization to be a CAS needs a specific kind of leadership style in order for CAS principles like complexity, unpredictability and self-organization to operate in a healthy fashion (Penprase & Norris, 2005). This leads me to think a CAS needs leadership that can embrace and facilitate change based on needs that emerge from the ground up, using a collaborative teamwork approach (Holden, 2005). A large facility like a hospital that is filled with a wide variety of patients, employees and dynamic forces can seemingly be impossible to adequately fund, staff, and manage. Using the CAS theory as an analytic frame will allow me to compare and contrast the current state of leadership and management in BC’s health care system,  CONTINUING PROFESSIONAL DEVELOPMENT  21 specifically hospitals themselves. Additionally, it will allow me to examine the role leaders play in supports and barriers nurses to access CPD activities.  Each theory in isolation has limitations on how it can inform this SPAR project. However, all three theories can collectively help gain new understandings as well as help explain why the answer to this problem needs to use multidimensional considerations. Particularly, using these theoretical perspectives amongst the unique collection of findings can enhance my analysis to give key stakeholders contextualized implications and recommendations for future policy reforms. As such, I will next describe the rationale for my methodology of choice.  Methodology  Due to the broad nature of this research project, I have selected to do a scoping review. A scoping review is a type of literature review that includes a wide variety of literature for consideration in order to gain a better grasp of what is generally known about the research topic. (Arksey & O'Malley, 2005). This conceptualization is particularly congruent with the purpose of my SPAR project since a scoping review can help the reviewee gain comprehensive coverage to “map rapidly the key concepts underpinning a research area,” (p. 21). It is especially appropriate in relation to my research question, in order to identify the structural barriers and supports that nurses experience in meeting their CPD requirements. The procedure for this scoping methodology is as follows: “Stage 1: Identifying the research question; Stage 2: Identifying relevant studies; Stage 3: Study selection; Stage 4: Charting the data; Stage 5: Collating, summarizing and reporting the results,” (p. 22). I identified the first stage in chapter one, and I will present stages two through five in this second chapter. Upon completion of the fifth stage, I will include a critical analysis, as this complex research question is embedded amongst a myriad of variables that requires thoughtful consideration prior to dissemination.   CONTINUING PROFESSIONAL DEVELOPMENT  22  I chose to start with a search in three separate databases: MEDLINE (Ovid), CINAHL, and ERIC. Since my search was an iterative process, I simultaneously used the snowball technique during my screening phase of the three databases. I used this technique by reviewing influential articles’ bibliographies to help include a comprehensive selection of literature that was not captured using traditional database channels (“Snowballing,” 2016). Lastly, I noted that Coventry and colleagues’ (2015) seminal integrative review excluded gray literature from government, policy and other organizations. My inclusion of grey literature will help uncover unidentified themes regarding organizational barriers and facilitators related to nurses’ abilities in meeting their CPD obligations.   Due to the purpose of my SPAR project and choice for using a scoping review, I need to ensure I have a comprehensive understanding of the knowledge available regarding my research question. This is also why the use of grey literature is necessary as part of my methodology. Grey literature consists of reports, white papers, information on policies that are typically more current and produced by organizations such as governments, relevant associations, and businesses (The UBC, n.d.). The UBC also strongly recommends the use of grey literature for scoping reviews. Finally, using this broad search strategy will help to better inform the context of my findings’ analysis in Chapter Three.   Search strategy. In this section, I provide further details regarding my approach and process for stages two and three of my scoping review. I explain how and where I searched for literature in relation to my research question. Then, I explain how and why I included and excluded certain articles that eventually lead to my final fifty-one selected works.   Database search. After several consultations with a nursing librarian, I decided to search the MEDLINE (Ovid), ERIC, and CINAHL databases. For ease, I have included visual and  CONTINUING PROFESSIONAL DEVELOPMENT  23 narrative descriptions for each database’s search strategy. For the MEDLINE (Ovid), ERIC, and CINAHL databases, I respectively include a narrative description that precedes a figure displaying a screenshot visual below: MEDLINE (Ovid) [(inservice training/ or staff development/) OR (Education, Nursing, Continuing/) OR (((staff or continuing) adj2 (educat* or develop* or train*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]] AND [(nurses/ or exp nurse practitioners/ or exp nurse specialists/ or nurses, international/ or nurses, male/) OR (Nurse*.ti,ab.)] AND [(organizational culture/) OR ((hospital* or organization*) adj2 culture*).ti,ab.)];           Figure 1. MEDLINE (Ovid) database search strategy completed on May 8, 2018.  ERIC [(acute care" OR "hospital" OR "organi*ation") AND (“nurs*”) AND ("professional development" OR "continu* education" OR "staff education" OR "continu* professional development")]  CONTINUING PROFESSIONAL DEVELOPMENT  24           Figure 2. ERIC database search strategy completed on May 11, 2018.    CINAHL [(MH "Professional Development+") OR "in-service training" OR (MH "Education, Continuing+") OR (MH "Education, Nursing, Continuing") OR (continu* OR staff) N1 (educat* OR train* OR develop*)] AND [[(MH "Nurses") OR (MH "Staff Nurses") OR (MH "Nursing Leaders") OR (MH "Nursing Staff, Hospital") OR (MH "Advanced Practice Nurses+") OR (MH "Nurse Administrators+") OR (MH "Nurse Researchers") OR (MH "Practical Nurses") OR (MH "Nurses by Specialty+")] OR (TI nurse* OR AB nurse*)] AND [(MH “Organizational Culture+") OR TI ( (hospital* or organization*) N1 culture* ) OR AB ( (hospital* or organization*) N1 culture* )];                   Figure 3. CINAHL database search strategy completed on May 11, 2018.   CONTINUING PROFESSIONAL DEVELOPMENT  25      Figure 4. PRISMA flow diagram describing the search strategy (Moher et al. 2009).  My search strategy included both main subject headings (i.e.: MeSH terms), as well as referencing scope notes for conceptual clarity. I also included keywords, truncation, and proximity operators as adjunctive search strategies to yield a wide range of literature due to the wide range of nursing nomenclature seen globally. Please see the top of the search flow diagram  Eligibility Identification  Selected Studies included   Screening  Records identified in CINAHL database (n = 712)   Records identified in ERIC database (n = 227)   Records identified in MEDLINE (Ovid) database (n = 377)   Records in CINAHL using limiters: English language and published within 15 years (n = 616)    Records identified in Ovid using limiters: English language and published within 15 years (n = 329) Grey literature search using limiters: English language and published within 15 years  (n = 13)   Records identified in ERIC using limiters: English language and published within 15 years (n = 54) Selected articles after duplicates removed (n = 891) (108 duplicates)   Articles excluded after title and abstract screen  (n = 784)   Full-text articles excluded   (n = 72)   Articles screened  (n = 110)   Selected articles after screening using eligibility criteria (n = 38)    Papers included in scoping review   (n = 51)   Snowballing using limiters: English language and published within 15 years (n = 3)   CONTINUING PROFESSIONAL DEVELOPMENT  26 for the total number of articles identified for each database using this search strategy, found in Figure 4. After the initial identification of records for the three databases, I chose to use an English language limiter, as well as studies published within the last fifteen years. The choice in choosing data from 2003 and onwards was threefold. Firstly, the provincial government started implementing changes to requirements for nursing education to be at a minimum of a baccalaureate degree in 2003 (CRNBC, 2012). Secondly, 2003 was the start of a transition of nursing as a designated profession from the Nurses (Registered) Act towards the Health Professions Act (Government of British Columbia, n.d.b). Both of these events may have potentially had an impact on how nurses are supported or hindered at the structural level to ensure their maintaining their CPD responsibilities. Lastly, limiting the search to the last fifteen years helped stay within the scope and timeframe of this research project.  For CINAHL, MEDLINE (Ovid), and ERIC databases, I used RefWorks citation manager to organize my identified articles. This software assisted me to de-duplicate my result to yield a total of 891 articles. I then scanned all their titles and abstracts using the following inclusion and exclusion criteria: Inclusion criteria. I wanted to review a variety of organizational supports and barriers of CPD in acute care settings, so I was generous in my inclusion criteria. This was an iterative process, as I often read the abstracts and titles several times prior to considering the article for inclusion. The following components were used in my screening process: • Any hospital/inpatient/tertiary care/acute care setting (including specialty hospitals, rural or urban settings);  CONTINUING PROFESSIONAL DEVELOPMENT  27 • Studies or articles targeting nurses employed in such organizations at any level (front line, advanced practice, research, unit managers, senior management, executive management, and so forth); • Both empirical studies as well as expert discourses and/or commentaries; • If the purpose of the article was to examine organizational, structural, or senior leadership level supports or barriers for CPD activities of registered nurses as conceptualized in Chapter One. For instance, I scanned for terms such as post-registration training, in-services, professional development, formal or informal (within and external to the workplace of a nurse), clinical/practice development, continuing education, learning beyond registration, evidence-based practice integration, and ethical practice supports. Magnet status/designation was also considered in this list as a ‘CPD’ term, as CPD is one of the major components of a facility being Magnet certified (Platts, 2018). Overall, if the title or abstract inferred a CPD activity that targeted the professional standards set by the CRNBC (i.e.: ethical practice, client-focused care, knowledge-based practice such as using Evidence-Based Practice, and professional responsibility/accountability), it was included for screening (CRNBC, 2018c).  Exclusion criteria. I excluded literature that exclusively studied or described settings that were located in non-acute care (clinics, long term care home, public health, home care, etcetera) since my research question is directly looking at acute care settings. I also chose not to include perspectives from those who were not nurses themselves (for instance, I excluded studies that solely examined other health care practitioners or students as their target populations). I believe nurses are in the best position to expose what is helpful and what hinders their abilities to engage in CPD. In regard to the type of literature, I excluded conference abstracts, interviews, and  CONTINUING PROFESSIONAL DEVELOPMENT  28 retracted articles due to their limited depth of information available for review. Although I did choose to include a wide range of studies that looked at various interpretations of CPD across the international settings, I entirely excluded studies that looked at job transitions, orientation, onboarding, job crafting, and dependent variables like job satisfaction, patient safety, retention, engagement, and recruitment. Lastly, I excluded studies that only examined individual or unit level facilitators or barriers for nurses to achieve their CPD duties.  Snowballing and hand selection of grey literature search. For this section, I also used the same limiters (English language, and published in the last fifteen years) to ensure consistency in my methodology. Snowballing and my hand selection of grey literature combined yielded a total of fifteen papers (please see Figure 4). For the two papers I chose using snowballing technique, I used the same inclusion and exclusion criteria as I had in my database searches. For my grey literature search, I used the same limiters. I did not use pre-determined inclusion or exclusion criteria for this latter search.  To start my gray literature search, I used a library guide provided by the nursing librarian (The UBC, n.d.). I started with using the PAIS Index as it includes dissertations and theses that I would not have known if I solely used hand selection, but also because it is an index of various policies that could perhaps inform the supports and barriers at the structural level. As such, the following is an example of the key terms used in this database: PAIS Index: (ab(hospital OR organization OR "acute care") OR ti(hospital OR organization OR "acute care")) AND (ab(nurse) OR ti(nurse)) AND (ab(professional development) OR ti(professional development)) However, I did not find any relevant literature using the PAIS index. I then proceeded to review BC and Ontario’s nursing professional associations’ websites for position statements and white paper publications. Also, I reviewed other education organizations such as the Carnegie  CONTINUING PROFESSIONAL DEVELOPMENT  29 Foundation for the Advancement of Teaching (CFAT), National League of Nursing, etcetera; searches informed by my professional experiences, recommendations from field experts, and the coursework in my graduate studies. In effort of gaining a better understanding of the organizational barriers and supports present in BC’s acute care settings, most of my grey literature search was focused on national or provincial organizations. This was also due to my database search strategy yielding limited provincial or Canadian information.   Findings  I present the fourth step of my scoping review, charting the data, in the Appendix. My final fifty-one findings are organized chronologically, from oldest to most recent, with an Asterix indicating which paper was retrieved using either snowballing technique or by hand selection of grey literature. Most of my chosen papers are from the United States, Australia, the United Kingdom, with select papers from Canada, Finland, Denmark, Israel and New Zealand. To display the data, I chose broad headings, including general information and citation information, but also country of publication, type of publication, as well as a summary of findings and key take-aways from the selected literature that was specifically related to my research question. I used the matrix method, found in Garrand’s (2003) textbook, to guide these decisions for organizing and presenting my findings from my selected papers.  Theme summaries. Amongst the literature, there were many recurring findings for how nurses can be supported and hindered by their acute care workplaces in achieving their CPD requirements. I have created five themes to summarize the findings:   Sense of community. One major theme that was an integral supporter of nurses’ CPD was ensuring there is a sense of community and teamwork across the entire spectrum of health care stakeholders. This includes nurses’ workplaces facilitating and nurturing partnerships within  CONTINUING PROFESSIONAL DEVELOPMENT  30 the nursing profession, the organization, and its allies in the community and governments (Barnsteiner et al., 2010; BC Coalition of Nursing Associations [BCCNA], 2016; Beal, Riley, & Lancaster, 2008; Black & Farmer, 2013; CFAT, 2018;  Drake & Berg, 2009; Ferguson-Paré, Mallette, Zarins, McLeod, & Reuben, 2010; Fleischman, Meyer, & Watson, 2011; NECBC, 2011; National League for Nursing, 2018; Paterson, Henderson, & Trivella, 2010; Race & Skees, 2010; Reno, Cerone, Ferket, Wojcieszak, & Reshoft, 2005; RNAO, 2004; Strickland & O’Leary-Kelley, 2009). Engaging in partnerships with international nurses and health care partners has also been seen as an imperative part of this theme (RNAO n.d.b.; RNAO, 2008). The need for nurses to support one another amongst all levels of health care is essential for nurses to meet their CPD responsibilities across all spectrums.   Vision and mission from leadership and management. Another resounding theme that has surfaced was found in domains of organizational strategy and policy. Often times, nurses’ CPD was found to be supported by their organizations if the overall strategic plan, model of care, and culture incorporate CPD in their vision and mission (Arthurs et al., 2018; Beal et al., 2008; Coventry et al., 2015; Drake & Berg, 2009; Fleischman et al., 2011; Webster-Wright, 2009; Wittmann-Price, Celia, & Dunn, 2013). A common mechanism for organizations to live these values is by utilizing an organization-wide professional practice model or education framework that is inclusive of fostering an environment that supports CPD (Arthurs et al.; Drake & Berg; Elliott, Ugboma, and Knight, 2012; Johnson et al., 2011; Mensik, Martin, Johnson, Clark, & Trifanoff, 2017; Moran, Duffield, Donoghue, Stasa, & Blay, 2011; Munro, 2008; Schulman, 2008; Shepherd & Harris, 2016; Steaban, Fudge, Leutgens, & Wells, 2003; Webster-Wright). Leadership and management can also embody this support through their explicit encouragement of all nurses within the organization to get involved with CPD (Beal et al.; Black & Farmer,  CONTINUING PROFESSIONAL DEVELOPMENT  31 2013; Chan et al., 2011; Fleischman et al.; Gould, Drey, & Berridge, 2007; Race & Skees, 2010; Strickland & O’Leary-Kelley, 2009; Tindale, 2005; Williams, 2010)    Overall, the organization can facilitate a vision and mission that is supportive of CPD by using transformational leadership styles, as well as promoting decision-making to include nurses who work at the frontline (Hockenberry, Brown, Walden, & Barrera, 2009; Steaban et al., 2003). A leadership style that inspires change, teamwork, and facilitates empowerment of others is known as a transformational leadership style (Arthurs et al., 2018; Bamford-Wade & Moss, 2010; BCCNA, 2016; Lewis et al., 2005; Race & Skees, 2010; Scully, 2015).   Finally, the vision and mission of the leadership and management team in the acute care setting is not only influenced by its nurses, but also by its provincial/state and/or national policies (Buscher, Siversten, & White, 2009; Byres, 2018; Elliott et al., 2013; Lewis et al., 2005; RNAO, 2014). The current health care system in BC is not set up to support an overarching mission of workplace practices that support nursing CPD.  Resource accessibility. This third theme amongst the findings was situated around access or lack of access to resources for CPD. This was presented in many forms such as insufficient and inadequate physical space for PD activities, insufficient trained nurse leaders to facilitate CPD for nurses, and limited options for in-house CPD programs (BCCNA, 2016; Beal et al., 2008; Canadian Association of Schools of Nursing, 2016; Eizenberg, 2010; Ferguson-Paré et al., 2010; Hockenberry et al., 2009; Katsikitis et al., 2013; Lewis et al., 2005; Moran et al., 2011; Munro, 2008; Paterson et al., 2010; RNAO, n.d.b.; RNAO, 2004; RNAO, 2008; RNAO, 2009; Steaban et al., 2003; Strickland & O’Leary-Kelley, 2009; Tindale, 2005). Often times, resource accessibility is perceived as insufficient in some areas due to poor communication of the already available resources nurses can use towards their CPD (Katsikitis et al., 2013; Schulman, 2008;  CONTINUING PROFESSIONAL DEVELOPMENT  32 Webster-Wright, 2009). Overall, this finding offers room to examine if this barrier for nurses to engage in CPD is an issue of insufficient resources, inadequate access, or both.   Commitment to learner-centered foci. When organizations offer a variety of learner-centered resources and mechanisms for CPD, nurses are supported to choose opportunities that are meaningful for their personal CPD journey within all domains and levels of experience (Barnsteiner et al., 2010; Black & Farmer, 2013; The Canadian Council on Learning [CCL], 2008; Drake & Berg, 2009; Elliott et al., 2013; Gould, Kelly, White, & Glen, 2004; Gould et al., 2007; Paterson et al., 2010; Reno & al., 2005). Examples of learner-centered foci in this scoping review are offering flexibility in PD activities, styles and schedules, as well as recognition of nurses’ previous learning experiences, to name a few (Black & Farmer, 2013; CCL, 2008; Elliott et al., 2013; Gould et al., 2004). In order to ensure these PD opportunities and activities are truly effective and learner-centered, both nurses and organizations can benefit from completing evaluations and needs analyses to optimize their capacities to support their nurses and overall facility (CCL, 2008; Munro, 2008; Reno et al., 2005; Steaban et al., 2003; Williams, 2010).   A baseline assessment and evaluation of an organization is critical in informing strategies needed at an organizational level to inform a culture of nursing excellence (Shepherd & Harris, 2016). I have also found that it is important to use results of such evaluations (in the form of return-on-investments and/or training needs analyses) to help facilities have a sustainable source of funding, but also to ensure their various resources and efforts are worthwhile and managed appropriately (Gould et al., 2004; Lynch & Happell, 2008b; Parsons & Cornett, 2011).   Optimized workplace environments. The final theme is centered around the impact of the greater organization on nurses’ workplace environments. In the context of organizational supports and inhibiting forces for nurses’ CPD, there were several components that emerged for  CONTINUING PROFESSIONAL DEVELOPMENT  33 each within this scoping review. Inappropriate workloads, bullying cultures, and a lack of time were all considered to be barriers by nurses within the practice environment (BCCNA, 2016; Coventry et al., 2015; Katsikitis et al., 2013; Lynch & Happell, 2008a; McCormack & Slater, 2006; Nevalainen, Lunkka, & Suhonen, 2018; Race & Skees, 2010; RNAO, 2009; Strickland & O’Leary-Kelley, 2009). Alternatively, several major attributes contributed to a positive and healthy workplace culture. These attributes include instilling an atmosphere of fun and humor, holistic supports for the nurse as a person, and most importantly - rewarding and recognizing its nurses (Bamford-Wade & Moss, 2010; CCL, 2008; Ferguson-Paré et al., 2010; Fleischman et al., 2011; Johnson et al., 2011; Lewis et al., 2005; Mick, 2011; Race & Skees; RNAO, 2004; Strickland & O’Leary-Kelley).   There are numerous factors that impact an organization’s environment, intersecting at the individual, unit, management, executive and government and association levels. Upon describing and examining the above findings, many interdependences and overlapping dynamics emerged. In this next chapter, I will use my selected theoretical frameworks to support my theme analysis before I offer the implications and recommendations of this scoping review.    Chapter Three: Critical Analysis Analysis of Findings  In isolation, each theme has interesting information that is relevant for organizations to consider in supporting their nurses’ CPD journeys. However, when one steps back to look at the five themes as a whole, it is apparent that they are interconnected and interdependent. I will first evaluate these themes individually, for their strengths and weaknesses, by incorporating theoretical worldviews from andragogy, complex adaptive systems and relational inquiry to assist my line of reasoning. Then, I will look at how they all intersect and inform the various  CONTINUING PROFESSIONAL DEVELOPMENT  34 domains of nursing practice. Evaluating the findings will help me avoid accepting the concepts and assumptions as they stand, and instead, will later allow me to diligently proceed into chapter four where I offer implications and recommendations from the results of this scoping review.  Sense of community. This theme encompasses how partnerships and mindfulness of shared interests and goals amongst individual nurses, stakeholders within an organization, and allies in the community and governments can improve nurses’ capacity for CPD.   At the ground level, organizations that create opportunities for nurses at all levels of experience to network with one another can facilitate nurses’ CPD (Black & Farmer, 2013; Drake & Berg, 2009; Ferguson-Paré et al., 2010; Paterson et al., 2010; Strickland & O’Leary-Kelley, 2009). Nurses can learn from one another’s strengths and experiences, learn about various opportunities and paths for growth, and even help discover potential mentors. This intra-professional collaboration is also enhanced in organizations that employ nurses in Advance Practice positions (Reno et al., 2005). Having senior leadership positions filled by nurses allows them to disseminate available resources and opportunities for PD to their colleagues, as well as a means to advocate for unavailable resources through the individuals in these formal positions (Drake & Berg; Reno et al.). Oftentimes, these resources were nurses themselves. Connecting nurses with mentorship and preceptorship opportunities in a thoughtful and strategic manner can help foster a nurse’s CPD journey (Beal et al., 2008; Drake & Berg; Race & Skees, 2010; RNAO, 2004). Black and Farmer (2013) described successful mentorship programs to ensure choice in the participation of both the mentor and mentee, and to be formalized, flexible, and thoughtfully curated. The Carnegie Foundation for the Advancement of Teaching (CFAT) (2018) considers mentorship in the workplace as fundamental for professional success. This Foundation’s philosophy suggests that for teachers to be supported in their development process,  CONTINUING PROFESSIONAL DEVELOPMENT  35 collaboration across the entire school and leadership team needs to be coordinated (Russell & Hannan, 2016). In the context of health care, Fleischman and her colleagues (2011) suggested in their case report that collaborating with other departments (for example, hospital library or other inpatient units) can also help maximize resources for nurses to use for their CPD. Fostering a sense of community to invite collegiality amongst nurses of varying experiences and within the organization itself is a tremendous support for nurses to be able to access CPD.   Belonging to a community, in this context, means that nurses, leaders, and organizations are in a position in which they all share resources and knowledge to ensure all stakeholders’ needs are met. Through these interactions, an exchange of information occurs to provide an opportunity for reflection, exposure to new experiences as well as exposure to peers’ experiences to foster nursing CPD – which are some of the conditions adults require for optimal learning (DeYoung, 2014a; Taylor & Kroth, 2009). Andragogy theory states adults learn better when they have identified a need to learn, in addition to learning through intra and inter-personal experiences (Knowles, 1985). Thus, when each stakeholder can engage in a dialogue with each other through identifying their own strengths and areas for development, they all can benefit by helping one another learn. Through this andragogy lens, organizations understand that formalizing a mentorship program in which they acknowledge the mentor’s experience also understand that mentees wants to learn from others’ experiences, and would thus offer supports for both parties during this process. Self-directed learning is not synonymous with independent learning. So, nurses who are motivated and ready to learn can leverage the resources drawn from their community of peers and workplace to maximise their CPD.  The practice of encouraging a sense of community to facilitate CPD for nurses should also extend towards other health care stakeholders in the community, provincially, and  CONTINUING PROFESSIONAL DEVELOPMENT  36 nationally. There has been a widespread call for action directed towards acute care facilities to collaborate with academic institutions, as well as professional associations (Barnsteiner et al., 2010; BCCNA, 2016; Ferguson-Paré et al., 2010; National League for Nursing, 2018; NECBC, 2011; Reno et al., 2005). This collaboration and resource sharing can benefit each participating party by, for instance, increasing cost efficiency and variety of opportunities for PD (NECBC). Specifically, Elliott and colleagues (2013) found that nurse leaders employed in a dual role in the acute care and academic settings can facilitate a partnership that is beneficial and functional for both settings. This was done by sharing resources, expectations, and clarifying perceptions of both organizations that are likely carrying out a similar vision and mission. At a global level, there are also mentorship opportunities for organizations as a whole. RNAO (n.d.a) has an international program called Best Practice Spotlight Organization that helps organizations connect with one another to share strategies for nursing excellence and use of best practice care. Collaborations with community partners and facilities such as these have supported nurses’ CPD journeys in several North American contexts; especially considering the variety of nurses’ shift schedules, PD needs, and geographical location that limit PD accessibility (Barnsteiner et al., 2010; BC Coalition of Nursing Associations, 2016; Ferguson-Paré, et al.). Recently, the BC Coalition of Nursing Associations (BCCNA) (2016) was able to actualize such collaborative work in practice. A policy forum that included governments, health authorities, students and nurses (RNs, Licensed Practical Nurses, Registered Psychiatric Nurses, etcetera) all met to discuss common interests, goals, and visions to reform health in BC. Using intra-professional collaboration, they were able to create and report contextualized recommendations for a policy reform - some recommendations that are currently in motion today (Clinical and Systems Transformation, n.d.). The BCCNA fostered an opportunity for intra-professional collaboration  CONTINUING PROFESSIONAL DEVELOPMENT  37 both as a means and as an end for the participating nurses CPD (Paterson et al., 2010).   Collaboration and partnerships are an innate part of nursing; a relational practice that requires nurses to know their scope and responsibilities in order to be able to co-facilitate a common goal for whom they serve. As discussed, this includes nurses’ engagements with CPD. If acute care nurses are in senior leadership positions or employed in dual roles within their academic facilities or professional organizations, the outcomes from these relationships for each party can be maximized through the use of theoretical principles from relational inquiry. For instance, relational consciousness can facilitate understanding of others’ differences, and use these differences as a resource to facilitate individualized CPD (Doane & Varcoe, 2015). With opportunities for networking, collaboration, and mentorship at the individual level or even the organizational level, the exchange of valuable knowledge and skills can provide a holistic approach by uncovering contextualized mechanisms for nurses’ CPD supports that would be mutually beneficial. Also, sharing of information and resources using a relational inquiry lens encourages nurses to simultaneously be mindful of sociopolitical contexts beyond the individual nurse and acute care setting, and ultimately brings attention to the greater forces that impact CPD (such as shiftwork, geography of nurses’ workplaces, Internationally Educated Nurse status, and so forth). This awareness of sociopolitical contexts, sharing knowledge, as well as a willingness for a sense of community can help diminish power hierarchies amongst the stakeholders by creating solutions that help one another to meet collective needs.   Finally, organizations can improve these connections by engaging in partnerships and innovative collaborations to provide the means and opportunities for nurses to engage in CPD. Ontario’s professional association, RNAO, (2008) reaffirmed the necessity for nurses to work with one another - even in an international context. Historically, there have been efforts to hire  CONTINUING PROFESSIONAL DEVELOPMENT  38 qualified nurses internationally to help increase Canada’s national supply of nurses (Runnels, Labonté, & Packer, 2011). For instance, RNAO recommends that Canada’s international recruiting efforts should not result in internationally educated nurses making Canada their new home. They claim that it is socially unjust because it perpetuates other nations’ nursing shortages. Instead, provincial and national policies must support internationally educated nurses who choose to come to Canada by providing the means for successful integration into the nursing profession. Ontario’s nursing association also advocated for nursing excellence to be a collective responsibility from the individual nurse, local health care stakeholders (including academic institutions and professional associations and organizations), and all levels of governments (RNAO, 2004). This position resonates with the findings in this scoping review in that there is an interdependency amongst nurses and their workplaces, community and global partners, as well as other macro level organizations to nurture a community with one another in order to meet the profession’s and health care system’s needs.   My conceptualization of acute care settings as a CAS can be used as a framework to understand the theme’s above conclusion. A CAS is known to have multiple stakeholders and agents that are in a continuous state of self-organization to reach equilibrium (Holden, 2005; Paley, 2007). One small part of this self-organizing process includes nurses who are willing to develop themselves to provide better patient care. CASs self-organize based on implied rules and overall cultures (Holden, 2005; Paley, 2007), and the widespread ‘rule’ of providing quality health care is shared by the organization and the greater community. Following this ‘rule’ drives decisions and behaviours, for instance, amongst health care teaching institutions and professional associations. As we have seen, some organizations have organized themselves in effort of abiding to this ‘rule’ by sharing PD opportunities with rural partners, or meeting with community  CONTINUING PROFESSIONAL DEVELOPMENT  39 stakeholders to create recommendations for policy reform related to financial and resources allocation in our current health care system’s context. The key principle of a CAS is that its agents are the drivers of how it operates, and this requires leadership that allows a ground-up change and governance. As such, the next theme is vital for such a process to succeed.     Vision and mission from leadership and management. This theme is situated within the domains of organizational strategy and policy, explaining that acute care settings need to incorporate visions and mission statements that are written in policies and truly lived by all levels of the organizations - especially those in leadership and management positions (Arthurs et al., 2018; Beal et al., 2008; Coventry et al., 2015; Drake & Berg, 2009; Fleischman et al., 2011; Webster-Wright, 2009; Wittmann-Price, Celia, & Dunn, 2013). A spirit of inquiry and development needs to be embodied by all levels of the organization (Arthurs et al.; Beal et al.). Overall, when organizations ensure their explicit and implicit values support a spirit of inquiry as well as nurses’ CPD, it is positively associated with nurses’ access to CPD practice (Drake & Berg; Fleischman et al.; Webster-Wright; Wittmann-Price et al.). More specifically, the overall strategic plan and model of care must incorporate CPD in their vision and mission.  These visions and values at the organizational level need to be aligned with the values of the nurses they employ (Arthurs et al., 2018). Nurses must reciprocate the value of CPD as well. Unfortunately, the current nursing shortage in BC does not position hiring managers to be selective in hiring nurses dependent on their value base (BC Nurses Union, 2018). Conversely, since CPD is greatly impacted by culture, nurses will be less likely to pursue or prioritize CPD engagement on an individual level if their organizations do not position PD to be valuable within its strategic vision (Coventry et al., 2015). When we examine the field of education, teachers’ CPD has been actively supported (Russell & Hannan, 2016). Specifically, Carnegie Foundation’s  CONTINUING PROFESSIONAL DEVELOPMENT  40 Network Improvement Community schools have an explicit value placed on improvement and development of teacher’s capacity and skills. These schools provided PD facilitators, coaching, an improvement framework, and more. This support from leadership matched the ongoing day-to-day PD that is teachers incorporate into their daily work. Their motivation for best practice and development is shared throughout all levels of the school, allowing actual embodiment of a CPD culture. Implicitly, ongoing development is also valued by staff, living PD in the day-to-day work within the walls of these schools. The same is suggested in the findings for nurses. Unless a shared value of developing nurses’ professional capacities is expressed and lived by the leadership structures in an organization, it will serve as a barrier for nurses’ engagement in CPD.  A common mechanism for organizations to live these values is by utilizing an organization-wide professional practice model or framework that is inclusive of fostering an environment that supports CPD (Arthurs et al., 2018; Drake & Berg 2009; Mensik et al., 2017; Munro, 2008; Schulman, 2008; Steaban et al., 2003; Webster-Wright, 2009). Using an educational framework that is structured for practice settings can help organize mentorship partnerships to be successful for both parties, including training for the mentors, collaboration of creating goals and purposeful PD selection, assessment and evaluations of the process and outcomes for both parties (Johnson et al., 2011; Mensik et al.; Moran et al., 2011; Munro, 2008). Shepherd and Harris (2016) used an andragogy framework to guide their plan of achieving Magnetâ designation, which was one of their organizational missions. In the UK, an iterative algorithm was used by Elliott and colleagues (2013) that incorporated elements of flexibility, tools, and both physical and health human resources to successfully help nurses achieve their CPD requirements. By having an organization wide framework, it also ensures the employer gives and offers each nurse an equitable opportunity for PD (Munro, 2008).  CONTINUING PROFESSIONAL DEVELOPMENT  41  It is imperative that leadership and management support CPD by explicitly encouraging nurses within the organization to get involved with their CPD (Beal et al., 2008; Black & Farmer, 2013; Chan et al., 2011; Fleischman et al., 2011; Gould et al., 2007; Race & Skees, 2010; Strickland & O’Leary-Kelley, 2009; Tindale, 2005; Williams, 2010). Senior leadership needs to explicitly encourage nurses to engage in activities, such as involvement in workplace leadership programs and offer nurses opportunities for career advancement, particularly to those who show interest and motivation (Beal et al.; Black & Farmer; Chan et al.; Fleischman et al.; Gould et al.; Race & Skees; Strickland, & O’Leary-Kelley; Tindale; Williams). Williams claimed that a neutral attitude by leadership and management can be perceived as a barrier by nurses. As such, positive reinforcement of PD activities is needed so the limited time nurses have to engage in CPD is indeed perceived as valuable to the overall organization. Executive leadership’s enthusiasm for CPD engagement and involvement is not only an important facilitator for nurses to actualize their CPD duties, but it is also vital to share this excitement and importance with other key decision makers in the organization to advocate for strategies to support nurses’ CPD for nurses (Black & Farmer).  Organizational embodiment of values that support CPD for all staff requires a likeminded culture. For instance, Steaban et al. (2003) found that a transformational leadership style was an antecedent to nurturing an organizational PD culture amongst nurses and executives alike. An American hospital succeeded with this culture shift by investing in PD resources, activities, and platforms for nurses, which ultimately empowered nurses to instigate organizational change through improvement of their leadership and policy analysis skills (Hockenberry et al., 2009). Similarly, incorporating a shared governance model supports nurses across the entire spectrum of practice to be involved in a forum that encourages the exchange of mutual needs and agendas  CONTINUING PROFESSIONAL DEVELOPMENT  42 (Arthurs et al., 2018; Lewis et al., 2005). In these published American exemplars, nurses were represented in other council and committees as well, such as those committed to research and education, clinical practice, quality and performance improvement, workplace environment, shared government councils. These platforms provided nurses the means to select the PD tools they needed to provide quality patient care. When nurses have the opportunity to engage in shared governance, it can be empowering and encourage collegiality amongst one another (Bamford-Wade & Moss, 2010).   In a local context, shared governance was perceived as a positive and required means for all nursing stakeholders in BC to implement changes for nursing models, staffing, and optimizing nurses’ roles (BCCNA, 2016). This experience in itself is a mechanism for engaging in CPD, and fits with an andragogy theoretical framework. However, a United Kingdom Advance Practice Nurse cautions that empowerment has the potential to paradoxically disadvantage organizations in which nurses work, since nurses may seek PD activities or employment opportunities outside their current employers (Williams, 2010). This may result in nurses leaving organizations in search for a workplace environment complementing their values and needs. It is key for organizations to allow agents with this CAS to self-organize, instead of resisting its natural movement. According to the CAS theory – such behaviour is unpredictable anyways and cannot be controlled (Paley, 2007). When leadership uses a transformational style, it can only inspire and influence the environmental culture to a certain extent; it is up to its agents, the staff, to adapt towards a state of equilibrium as they see fit (Paley). Nevertheless, using some of the above principles of transformational leadership styles can create conditions that support the needs and desires of the organization and the health care professionals it employs.   CONTINUING PROFESSIONAL DEVELOPMENT  43  Undoubtedly, there are many forces that impact the vision and mission of an organization’s leadership and management. Each organization has its explicit strategic plan that is typically made up of facility-wide values, goals, vision and mission. The values that underpin the vision of an organization are not fixed, but rather fluid like the dynamics within a CAS. In order to reach equilibrium, all the agents within an organization self-organize in an unpredictable fashion. Leadership needs to be acknowledge this condition, rather than repress it. Although unpredictability may not be perceived as a good thing, the findings within this theme complement this principle by revealing that leadership and management should allow its nurses and other staff (i.e.: ‘agents’) the opportunity to engage in shared governance and other committees. CASs are dynamic and complex, and to try and have a central control of autonomous and capable professionals would be poor use of leadership resources and potentially cause clashing interests. These collective decision-making processes can consequently shape the overall organizational culture to be one that is functional. Nonetheless, this practice alone will not impact the organizational culture to be CPD friendly; leadership and management need to visibly encourage their nurses to engage in activities that will inspire them to be their best professional selves.   This inspiration is needed to help nurses engage in their CPD learning, as per the andragogy theory (Knowles, 1985; Taylor & Kroth, 2009). Although this theory stipulates that learning is primarily internally driven, if the vision and mission set out by the leadership and management encourages CPD of its staff to improve professional practice to ultimately facilitate better patient care, this encouragement will ultimately influence their orientation and readiness to learn. This further supports the inclusion of an educational or development framework to be embedded in the organization’s strategic plan in order to facilitate nurses’ and other staff’s CPD  CONTINUING PROFESSIONAL DEVELOPMENT  44 journey.   The influence of a vision and mission also comes from provincial/state and/or national leadership and management levels. For instance, a multinational European evaluation survey by the World Health Organization acknowledged that in a medically-dominated culture, nurses and midwives need stronger regulatory and association representation to advance their professional needs at the structural level (Buscher et al., 2009). Not only is a strong national nursing association important, but a culture that respects and values the capacity and potential of nurses’ contributions to health care is also crucial. A societal culture that shares the latter belief is fundamentally needed before public funding for CPD can be justified by policy makers and political representatives. This finding is corroborated by an exemplar from the state of Texas outlining their support for nurses via an ongoing grant to cover costs that nurses require to engage in CPD (for example: childcare, transportation, resources, education, and so forth) (Lewis et al., 2005). This fund illustrates what a systemic support can be in order for organizations to embody their vision for nursing excellence. Similarly, the United Kingdom’s National Health Service made a similar investment in formal education and other study opportunities such as providing academic support, tutoring, and a mix of resources catered to the learner’s needs (Elliott et al., 2013). In 2014, the need for structural supports was acknowledged in Canada by the RNAO, who explained that nurses’ capacities and potential for healthcare innovation must be nationally appreciated and valued before any revised Health Accords can incorporate facilitators for nurses’ CPD. Recently, at a local level, BC’s nursing policy secretariat reported the need for current nursing leaders to advocate for the nursing professions’ needs to governments and other associations in order to get the tools and resources required for optimizing various nursing roles (Byres, 2018). Byres also advocated for a review of current education models and continuing  CONTINUING PROFESSIONAL DEVELOPMENT  45 education by governments and academia (with collaboration of multiple disciplines’ stakeholders) and recommended consideration of alternatives. If governments, health authorities and the public share the values, vision and mission of these acute care settings for their share in the accountability for supporting CPD, these organizations would be better positioned to affect decision-making that enables policy reform and praxis to occur.   An organization’s embodiment of its role in supporting nurses’ CPD is indeed influenced by the greater political systems. “The values and goals of a culture and society have an effect on the political system of a country that in turn shapes policy on education, health, health care, and research,” (Gaudine & Lamb, 2015, p. 38). Thus, bearing in mind a theoretical worldview of relational consciousness and inquiry (Doane & Varcoe, 2015), it must be acknowledged that outside the walls of the acute care setting, there are societal influences as to which values are enacted within the organization. These societal values, in conjunction with nurses’ professional code of ethics and personal values, all intersect and inform our colleagues’, patients’ and leadership’s values - and vice versa. Values primarily inform actions, particularly in relation to others, so if there is incongruence in the belief system amongst nurses, allied staff, leadership, the organization and society then there will be disagreements in how a professional body, organization and even health care systems ought to be managed. Therefore, each stakeholder will likely have a different belief regarding where time, money, and other resources ought to be spent; from the individual nurse to the federal government levels.   Although an organization like a hospital is a CAS itself, it is comprised of smaller and numerous other CASs. The behaviour within these CASs are not immune to the outside world, and as such, will iteratively organize in relation to one another in downward causation (Paley, 2007, p. 236). If wider societal policies resist organizational support for nurses’ CPD, the  CONTINUING PROFESSIONAL DEVELOPMENT  46 findings from this theme cannot be implemented or actualized. Once there is data, awareness, and acknowledgement by all stakeholders regarding the degree of positive impact that CPD can yield for nursing and patient outcomes, only then can there be a unified vision, mission and shared accountability for CPD by the organization and greater health care system. As such, the findings within this theme are only theoretically plausible, and would require a significant culture shift to be practically enacted.   Resource accessibility. This third theme amongst the findings was situated around the ideology of resource scarcity. For instance, most health care professionals have unequal access for opportunities and/or means to engage in work-based CPD activities due to poor infrastructure such as insufficient and/or inadequate physical space (BCCNA, 2016; Eizenberg, 2010; Strickland & O’Leary-Kelley, 2009). Nationally, there is a continued shortage of trained and prepared nurses that are available to work in formal positions such as educators, research facilitators, and mentorship coordinators (Canadian Association of Schools of Nursing, 2016; RNAO, n.d.b.; RNAO, 2008). Expert reviews and surveys explain that hiring trained nurse leaders is key in bringing attention to and facilitating CPD needs of the nursing profession at all levels (Byres, 2018; Chan et al., 2011; Race & Skees, 2010). If there are not enough nursing leaders to facilitate PD, it is unlikely that nurses will get the support they need from their employers.   Accessibility to CPD resources and opportunities is also affected by nurses’ geographical locations and their work schedules. Specifically, nurses who work in rural acute care facilities face barriers in accessing PD opportunities (Ferguson-Paré et al., 2010; Moran et al., 2011). Ferguson-Paré and colleagues experimented with a way to mitigate geographical barriers: they partnered with urban and rural facilities to share resources and incrementally exchange staff to  CONTINUING PROFESSIONAL DEVELOPMENT  47 expose them to new learning opportunities. Nurses working in various geographical areas across the entire acuity spectrum have been disadvantaged in their access to CPD, particularly those working in rural areas (RNAO, 2009; Steaban et al., 2003). In BC, nurses working in rural and remote acute care facilities are further disadvantaged by practicing in areas that already have trouble with retention. This is a result of external influences like high costs for food and housing, as well as challenges to family life dynamics unique to those living in remote communities (BC Nurses’ Union, 2018). These added challenges limit their capacity to engage in CPD outside their workplace. Furthermore, in the context of work-based CPD opportunities and supports, shiftwork and rigid work schedules have also been found to hinder nurses’ access to PD; nurses who work part time and night shifts are particularly affected (Gould, et al., 2007; Moran et al.; Schulman, 2008). Meanwhile, Moran and colleagues found that implementing job share positions and allowing flexibility in hours through friendly scheduling policies have helped diminish this latter barrier. According to nurses’ perceptions, organizations and higher structures need to consider all nurses and their associated levels of experience and work-life contexts, rather than offering PD activities and resources to select nurses (Katsikitis et al., 2013; Munro, 2008).   The theme of resource accessibility, or lack thereof, highlights serious structural gaps; particularly when relational consciousness and inquiry are used to identify the praxis required to help overcome this issue of unfair resource distribution. Based on the findings from my scoping review, it is apparent that acute care organizations and the overall health care system are lacking an appropriate response to the greater contexts for the nursing workforce. Locally and internationally, nurses are exposed to limited physical and human resources. They work in disadvantaged staffing conditions and geographical locations that limit their own capacity to  CONTINUING PROFESSIONAL DEVELOPMENT  48 engage in CPD independently, let alone be supported by their workplace facilities in this venture. In an acute care facility’s effort to prioritize the needs of the public through offering continuous nursing care and tertiary care services, the needs of the nursing workforce have been undermined; and in some respects, ignored due to the assumption that nurses’ self-regulation for their practice is an independent venture (Cehic, 2017b). Employers rely on nurses to meet their own CPD obligations. For instance, these findings demonstrate that when a nurse is working a night shift in a rural hospital, they have limited (if any) nursing leaders or physical resources to draw on for their CPD within the organization. This issue of limited resources affecting training and education is only one of many outcomes for nurses working in these remote communities. Ineffective resource allocation (both physical and human health resources) also propagates safe staffing issues that impact nurses’ abilities to provide safe and dignified patient care within such unsafe workloads (BC Nurses Union, 2018). These variables are not modifiable by nurses themselves, and the authority vested in organizations must be used to manage the funds and resources in an innovative way that directly affects the contextual and unique needs of each acute care facility and its nurses. Organizations must at the very least provide the staffing and resources to provide safe patient care, but also the resources and leadership to foster CPD so nurses are equipped with the knowledge for up-to-date and best practice. The exemplars discussed earlier by Moran and colleagues in Australia (2011), as well as Ferguson-Paré and colleagues (2010) in Ontario demonstrate how organizations can help close the gap in resource distribution and availability.  Implementing work-based CPD supports and programs is a resounding finding in the literature in order to overcome the access inequities to resources (Beal et al., 2008; Hockenberry et al., 2009; Katsikitis et al., 2013; Tindale, 2005; RNAO, 2004). For instance, findings from  CONTINUING PROFESSIONAL DEVELOPMENT  49 Beal et al.’s qualitative study suggested that nurses in three centres all believed CPD should be embedded as a part of their daily nursing practice. These findings are similar to how adult learning is conceptualized: adults often feel responsible for their own learning, use experiences as a resource, and are oriented to developing their knowledge based on their identified need (Taylor & Kroth, 2009). Therefore, if PD is contextualized within nurses’ practice while also being given the time and resources during their shift, the chance for CPD engagement could be improved.  Incorporating a Professional Practice committee in the organization has also been suggested to help support nurses in maintaining a PD portfolio to help manage CPD (Lewis et al., 2005). An Australian hospital used nurses’ work environments and practice experiences to inform their in-house leadership program (Paterson et al., 2010). Programs curated in the facility helped utilize the skills and wide array of experiences from their staff and contributed to a shift towards a positive workplace culture that benefits the nurse and organization (Hockenberry et al.; Paterson et al.; RNAO, 2004; Williams, 2010).   Often times, insufficient communication of the resources an organization can provide is a barrier for nurses in accessing available CPD benefits (Schulman, 2008). This finding extends to various misunderstandings and interpretations of PD amongst all stakeholders (Webster-Wright, 2009). Furthermore, Katsikitis and colleagues’ (2013) descriptive study found nurses and midwives were unsure of what was considered a CPD credit in Australia, a nation that had implemented PD regulation. Clear expectations need to be communicated across all levels of the nursing profession for successful CPD engagement (CCL, 2008). Communication, infrastructure, and distribution of PD resources are all vital variables for organizations to consider and evaluate when examining their own organization’s influences on nurses’ CPD.    CONTINUING PROFESSIONAL DEVELOPMENT  50  Commitment to learner-centered foci. When organizations offer a variety of learner-centered resources and mechanisms for CPD, nurses can choose opportunities that are meaningful for their personal CPD journey across the entire career trajectory - from the bedside to executive positions (Barnsteiner et al., 2010; Black & Farmer, 2013; Gould et al., 2007; Paterson et al., 2010). Nurses are supported when organizations look at all the various generations and experiences of nurses available in their facility, offer resources they have requested, and have the facility use this information to leverage their experiences to support one another (Drake & Berg, 2009; Reno & al., 2005). Acute care settings that use a learner-centered focus can do so by offering flexibility in PD activities, style and time frames, as well as acknowledging nurses’ prior education and learning experiences (Black & Farmer, 2013; CCL, 2008; Elliott et al., 2013; Gould et al., 2004). Learner-centered resources may include offering information databases and encouraging use of best practice guideline offered by nursing associations (RNAO, 2004). Lastly, organizations can complete an analysis of their nurses’ needs to ensure their efforts are effective. For instance, Reno and colleagues (2005) found that an Illinois hospital invested in their health human resources by implementing a new graduate residency program after they identified their new graduate nurse employees are having trouble working within their full scope. Organizations need to understand and evaluate their nurses’ needs before they can support them.  A workplace can conduct both an assessment and evaluation to verify if they are using a learner-centered focus to support their nurses’ CPD needs. Assessment and evaluations are an important part of a CPD journey, and involve multiple assessors, such as the learner themselves. This feedback helps provide information regarding how effective learning is for the nurse, in addition to providing information on how effective and relevant the PD activity is itself, the  CONTINUING PROFESSIONAL DEVELOPMENT  51 quality of the education material, and efficacy of those who are facilitating it. Assessments and evaluations are sometimes seen as an interchangeable process. Assessments provide ongoing informal information about a learner’s progress and help shape the learning process; while evaluations provide a concrete measure if learning objectives have been achieved (DeYoung, 2014b; Fenwick & Parsons, 2009). The Canadian Council on Learning (2008) places importance on an assessment and evaluation of individuals to supplement a learner-centered approach, while the CFAT (2018) considers evaluation of their teachers in the workplace to be fundamental for their teachers’ success. The concept of learners using their assessment findings to support their learning is aligned with andragogy theory, in that they use their experiences to inform their development of new knowledge (DeYoung, 2014a). Depending on how they are used, both assessment and evaluation processes provide feedback to the involved stakeholders to inform how CPD can be learner-centered.  An organization can feasibly implement a learner-centered focus by implementing a simple and streamlined assessment process of their nurses (Steaban et al., 2003). Barnsteiner and colleagues (2010) suggest it is helpful to do this in a non-punitive manner, ensure goal setting is facilitated, and link the findings to PD resources best suited for the respective nurse.  This evaluation process also needs to extend beyond the individual level. An assessment and evaluation of the current PD status in an organization is critical in informing strategies needed at the systemic level to inform a culture of nursing excellence (Shepherd & Harris, 2016). Using evaluations like return-on-investments and training needs analyses can help sustain relevant PD resources and activities, and also help justify an organization’s investments (Gould et al., 2004; Lynch & Happell, 2008b). It can even provide a benchmark for individual nurses, those in leadership, and in at the systemic level to plan and measure CPD strategies. When evaluations  CONTINUING PROFESSIONAL DEVELOPMENT  52 are done both at an individual and systemic level, information regarding what nurses need and value can be used to inform decisions for how the facility should move forward as a whole, rather than in opposing or conflicting directions (Munro, 2008; Steaban et al., 2003; Williams, 2010).   When acute care settings provide the means for the leadership and management to be mindful and attentive to each of their nurses’ PD needs within the greater context of the workplace, they innately foster an environment that values its people - from its staff to its patients. A facility’s conscious effort to use and explore their nurses’ experiences, PD needs, learning styles, and evaluation results are all examples of how, “those interrelationships […] inform action toward patient, nurse, and system well-being,” (Doane & Varcoe, 2015, p. 6). An organization’s commitment in using a learner-centered focus is aligned with a relational inquiry worldview; they share the responsibility for each nurse’s success in good patient care through informing themselves of the surrounding context that must be considered when investing time and resources in supporting nursing PD.   An ongoing commitment to offer learner-centered opportunities for nurses’ CPD demonstrates that facilities acknowledge the value of investing in each nurse, which concurrently diminishes preferential treatment and improves equitable and fair supports for their nurses. When an organization recognises each learner’s individual PD needs, and subsequently conducts evaluations to ensure appropriate supports and efforts are indeed in place, it can naturally provoke the nurse to gain awareness of their own PD needs and the resources that are available through their workplace environments. Since andragogy theory stipulates that nurses feel responsible for their own learning and are ready to learn once they see the need to learn, that reflective process that organizations have facilitated can trigger and support its nurses’ CPD  CONTINUING PROFESSIONAL DEVELOPMENT  53 through this commitment to learner-centered considerations for PD (Taylor & Kroth, 2009). This andragogical assumption and scoping review theme theoretically debunk that paternalistic choices in PD offerings are helpful and effective for nurses. Meanwhile, we must remember that health care organizations are fluid and dynamic CASs (Holden, 2005; Paley, 2007). Their pursuit towards a self-organized state of equilibrium is ongoing, just like a nurse’s PD needs. This is why the theme of organizations ongoing commitment to learner-centered foci of its nurses is imperative for success in supporting nurses in their CPD.   Finally, a commitment to a learner-centered focus requires an ongoing dedication to financial, leadership, and management resources to support sustainable CPD for nurses (Parsons & Cornett, 2011). To ensure organizational supports of CPD resources can thrive, Arthurs and colleagues’ (2018) descriptive case report implied organizations must hold themselves accountable to nursing excellence. For example, this review’s findings helped me identify that CPD needs can be addressed through focusing on strategies that aim to diminish the turnover of nursing positions at any level within acute care centers (Parsons & Cornett; Race & Skees, 2010). Dedicating such health human resource supports must also be managed within a learner-centered framework. Paradoxically, Katsikitis and colleagues (2013) discovered that when health human resources were used to regulate nurses’ CPD via an evaluation process, it was perceived to be a barrier in their CPD endeavors. Nurses found it hard knowing what qualified as PD, knowing how to properly document it, and poor health human resource availability to engage in PD. Further coordination and communication amongst all involved stakeholders can maximize nurses’ sense of relevancy and engagement. However, a healthy practice environment is needed for such PD coordination. Workplace environments made a big difference in nurses’ abilities in meeting their CPD obligations; which is my next focus of analysis as well as the final theme.   CONTINUING PROFESSIONAL DEVELOPMENT  54  Optimized workplace environments. The last theme amongst the findings was situated around the positive and negative organizational impacts on nurses’ CPD. I will first describe those perceived by the nursing community as barriers. Then, to end on a hopeful note, I will proceed to describe what nurses perceive to be a conducive practice environment for facilitating their PD journeys.   Firstly, an inappropriate workload is seen as a significant and practical barrier within the practice environment in order for a nurse to engage in PD. Coventry and colleagues’ (2015) integrative review revealed a heavy workload and patient care was a barrier in accessing work-based education or training opportunities. The same was echoed in a systematic review of qualitative studies, where routine nursing duties did not give nurses the opportunity to engage in reflective practice or to, “evaluate their own actions or the actions of the whole work community,” (Nevalainen, Lunkka, & Suhonen, 2018, p. 27).  Similarly, McCormack and Slater’s (2006) qualitative study provided examples of nurses in clinical leadership positions, such as Clinical Education Facilitators (CEF), who experienced a similar barrier. This facility employed only a handful of CEFs, which ultimately increased their workload and limited their capacity to support nurses’ CPD. They needed more CEFs to effectively support all nurses, not just new orientees and new graduates. As previously discussed, CPD can be a factor in helping nurses provide safer professional practice. Strickland and O’Leary-Kelley’s (2009) cross sectional survey of clinical nurse educators also indicated that a heavy workload was a barrier for nurses to engage in ongoing and safe professional practice. At a macro level, it is clear that organizations must be supported with a financial and health human resource supply to have the means to provide nurses safe patient ratios, which is reported to be an antecedent for nurses to have time and energy in engaging in CPD resources and activities to improve patients’ chances  CONTINUING PROFESSIONAL DEVELOPMENT  55 for quality nursing care (RNAO, 2009).   The other two barriers seen in poor practice environments are workplace bullying and lack of time. Several sources attributed the presence of workplace bullying to discourage nurses’ engagement with CPD – amongst many other poor outcomes (BCCNA, 2016; Lynch & Happell, 2008a; Race & Skees, 2010). If workplace bullying is understood relationally, the assumption is that it is an issue that is influenced by intrapersonal, interpersonal and contextual factors (Doane & Varcoe, 2015). For instance, its presence is likely occurring within an unhealthy organization that perhaps misuses power hierarchies both intra-professionally and inter-professionally, and possibly uses transactional leadership styles in the management team (i.e.: top-down leadership and management style) (Fleming, 2016). The wider context and influencing factors must be considered if this barrier is to be addressed and resolved. Secondly, CPD was seen as encroachment on nurses’ and midwives’ personal time in Coventry and colleagues’ (2015) review as well as Katsikitis and colleagues’ (2013) descriptive study. To help counter this problem, some facilities have provided ‘release time’ to engage in research activities (Barnsteiner et al., 2010). Other facilities have explored the inclusion of CPD within the nurses’ position, as well as protected and paid time where patient care is not expected (Beal et al., 2008; Chan et al., 2011; Munro, 2008). This suggestion assumes that there are health human resources available to provide patient care coverage. These three barriers are seen in the collated findings as areas that require a change in order for an organization to be able to support its nurses with an optimal work environment for CPD to ensue.   Structural barriers like heavy workloads, lack of time, and workplace bullying are several of the major claims found in the scoping review that limit nurses’ capacity in meeting their CPD obligations. Already it is clear that other themes that have been discussed thus far impact these  CONTINUING PROFESSIONAL DEVELOPMENT  56 barriers, such as resource accessibility and the vision and mission of the leadership and management. Through the use of a critical lens, we can see how the division of labour in BCs health care system has undermined the needs and workplace conditions of nurses to be able to provide competent and evidence-based nursing care.   The socioeconomic environment in Canada’s health care system is situated within a liberal individualist society, one that has gradually etched away at a health care system that was intended to serve social welfare (Bourgeault, 2010). With the way health care is currently financed, the policies and politics have ultimately affected the heavy workloads and lack of time nurses experience to engage in their CPD. Considering hospitals and physicians are one of the major publicly funded health care services, we must acknowledge this socioeconomic environment in which acute care settings’ nurses work; their employers are financially influenced to find ways to decrease operational costs while simultaneously increasing health human resource productivity, increase patient turnover, and decrease length of stay (Bourgeault; Duncan et al., 2014; Tomblin Murphy et al., 2012). The mechanism for remuneration particularly affects the way health care services are managed, which includes utilizing the cheapest available health care providers (like nurses) to deliver patient care and maximizing nurse-patient ratio (Duncan et al.). However, the oversight with this arrangement is that quality of patient care is affected if time for CPD is not factored into the nurse-patient ratio, which simultaneously worsens nurses’ workload.   In regard to positive attributes, major findings included a positive workplace culture, one that has a sense of fun and humor, and most importantly rewarding and recognizing its nurses. In particular, Strickland and O’Leary-Kelley (2009) report that a MagnetÒ facility, versus non-MagnetÒ, continues to be perceived as a supportive workplace culture for nurses to engage in  CONTINUING PROFESSIONAL DEVELOPMENT  57 CPD. Other components such as finding humor and friendly competition in CPD activities, as well as extracting learning opportunities in daily successes and failures in a non-punitive practice environment were both assets in facilitating CPD for nurses (Beal et al., 2008; Mick, 2011; Webster-Wright, 2009). Also, the literature reports that when workplaces have holistic supports that take nurses’ life contexts into full consideration for CPD planning, nurses will be much more motivated to be their best professional selves (CCL, 2008; Lewis et al., 2005; Ferguson-Paré et al., 2010). Most importantly, nurses’ efforts and achievements need to be celebrated (Fleischman et al., 2011; Johnson et al., 2011; Race & Skees, 2010). Rewarding and recognizing nurses’ work and career milestones has been consistently reported to help sustain nursing excellence (RNAO, 2004; Bamford-Wade & Moss, 2010; Fleischman et al.). Having financial rewards, or acknowledgement of achievements has been associated with improved nursing engagement (Chan et al., 2011; Race & Skees; Steaban et al., 2003). This is perhaps due to nurses using one other’s experiences as a resource for learning, and encourages a personal readiness to learn (Deyoung, 2014a). Without celebration of nurses’ achievements in relation to their patient care and PD activities, it can limit nurses’ awareness of the impact they have on their patients, colleagues and organization. This lack of awareness poses a risk for, “[nurses]…to be practicing in relational oblivion,” (Doane & Varcoe, 2015, p. 7), hindering nurses’ capacities to persevere through constraints encountered in their practice environments. Nurses practicing in relational oblivion may not recognize the extent or impact of their patient care, and it can pose difficulties in meeting their professional obligations. When organizations reward and/or recognize nurses, it can facilitate and positively reinforce their sense colleagues and the overall organizations’ climate.   However, one study found that financial compensation was insufficient on its own  CONTINUING PROFESSIONAL DEVELOPMENT  58 (Katsikitis et al., 2013). For example, an alternative mode of recognition can be when organizations esteem their nurses’ knowledge by inviting them to help and offer their expertise in mentoring novice nurses; program planning, and so forth (Johnson et al., 2011). CPD can be facilitated by leveraging the experiences of their nurses in a localized context, which is one of the six assumptions that andragogy theory states are vital for both the mentor and mentee in successful PD (DeYoung, 2014a; Taylor & Kroth, 2009). Furthermore, Schulman (2008) and Tindale (2005) suggested that career advancement within the organization should be based on professional merit via participation in CPD activities, rather than solely on years of seniority. Overall, these top attributes that have surfaced in the scoping review for an optimized practice environment in an organization are required for nurses to feel supported in their journey in CPD.  Discussion   After analyzing the five themes using the CAS, andragogy and relational inquiry paradigms, it is clear that these themes are all interdependent in terms of their influence exerted on nurses’ CPD. Unmistakably, the foundation of all decision-making and behaviour are dictated by values. As such, the vision and mission from leadership and management is at the foundation of the other four themes, whereas a commitment to a learner-centered focus is embedded and a stipulation of all the other themes. Meanwhile, having equitable resource accessibility requires a sense of community. For any of these themes to be actualized in practice, an optimized workplace environment is necessary to provide the means to implement the vision and mission of an organization. Many of these themes have potential to synergistically work with one another, for instance, using transformational leadership style to facilitate intra-professional collaboration and a positive workplace culture (Bamford-Wade & Moss, 2010). Interestingly, the ebb and flow between the findings from this scoping review coincides with the ongoing and iterative nature of  CONTINUING PROFESSIONAL DEVELOPMENT  59 a nurse’s CPD process.  Acute care settings are continuously changing systems, which cannot be controlled due to their self-organizing nature. “Self-organisation does not entail that the behaviour of a CAS is independent of its environment…the environment is precisely what a complex adaptive system adapts to,” (Paley, 2007, p. 236). Their ever-changing dynamics adapt to the conditions in which they operate. Perhaps this is why, collectively, these themes complement a worldview in which an acute care setting must function within a facilitator role - by providing optimal conditions for CPD so that an organization can self-organize according to its own unique contexts and needs. Considering CPD is a professional expectation, a culture for nursing CPD can be instilled within an organization by facilitating their journey through the use of supports that are aligned with adult learning theory principles. Senior leadership commitments to using learner-centered foci, a collective vision for a CPD environment, collaborations with its community and to improve resource accessibility, while simultaneously optimizing the workplace environment for PD success, it demonstrates its sense of accountability to share responsibility in safe health care delivery.  Limitations  The content of this SPAR project does have several limitations. Methodologically, a scoping review can only provide a certain degree of depth to the information yielding within the findings. Furthermore, the derived content is also limited in terms of its applicability in the implications for the various nursing domains. The following information must be considered when one reviews the implications and recommendations in chapter four.   Methodological limits. Although this methodology allowed for an in-depth review of a broad research question, this process was not sensitive to solely selecting peer-reviewed articles,  CONTINUING PROFESSIONAL DEVELOPMENT  60 or empirically tested studies (Arksey & O'Malley, 2005). For this reason, I did not formally appraise any of the articles. However, I included specific limitations and/or strengths for each piece of literature located in the table of findings within the attached appendix.   Furthermore, there were limitations in my selection of articles for this scoping review. After the language and publication year limiters were applied in the database searches, the 891 articles did not all have an abstract to screen (see Figure 4, in chapter two). This posed a risk to have prematurely excluded a relevant article. Although I did conceptualize CPD based on content from seminal literature, my definition of CPD may not have been theorized the same way as my final fifty-one papers. This logic also extends to the fact that, internationally, terminology that reflects CPD the way I have conceptualized is vastly different (Webster-Wright, 2009). Perhaps, authors may have given key terms that were not reflected in my database search. Additionally, despite my efforts in being transparent with my choice in inclusion and exclusion criteria, my selected articles were limited based on my subjectivity in how I conceptualized CPD in chapter one.   Content limits. Since my data was not entirely empirical, inferences cannot be made based on this review’s findings. Instead, correlation, descriptive, and expert opinion data have been derived to inform implications for the nursing profession. This decreases the validity and transferability of some of my findings.   The fifty-one chosen articles and reports did not always report complete data regarding the logistics of their projects, how they were funded, staffing ratios, leadership styles used in their facilities, and geographical dynamics that may impact the dynamics in their respective practice settings. Although I included an international mix of literature to gain a broad understanding of CPD barriers and supports across the globe, I do want to acknowledge that  CONTINUING PROFESSIONAL DEVELOPMENT  61 some of the views surfaced in the findings may not be in line with the sociopolitical and economic culture in Canada. For instance, many of the American and Australian studies had privately funded hospitals that were described in their data. In BC’s context, this can affect the feasibility of certain supports and perhaps dim the light on barriers that are not apparent in the private sector.  For this reason, I will cautiously take that into consideration in the following chapter.   Lastly, I recognize that in my analysis, I did not discuss interdisciplinary health care professionals (HCPs) in relation to nurses’ in acute care settings. They certainly are an integral factor and significant variable in nurses’ means to engage in CPD, and some findings did suggest partnerships with allied HCPs to be considered as a strategy, which I will discuss further in the following chapter. This choice was made due to the scope of my research question, as well as the allotted time available to conduct this review and research project.  Chapter Four: Implications and Recommendations  The structural supports and barriers that impact nurses’ abilities in meeting their CPD obligations that I found in the literature all have repercussions in various domains of nursing practice. In this chapter, I will first focus on the consequences of these findings in the practice, education, leadership and research domains of the nursing profession within the BC and greater Canadian context. To complete this SPAR project, I will offer recommendations for distinct stakeholders – from those involved in nursing practice to nursing policy.  Implications    Nursing Education. Nursing students are encouraged to be lifelong learners.  Embodying this philosophy requires nurses in practice to have opportunities to pursue professional development. Nursing education needs to evolve to adopt the philosophies and  CONTINUING PROFESSIONAL DEVELOPMENT  62 theoretical frameworks from this scoping review. This means nurses across the entire career trajectory would be considered worthy of educational investment, and not just students at the pre-licensure levels. Currently, both education and health care delivery are provincially regulated, but the two ministries are funded, managed, and staffed within their own silos (Government of BC, n.d.a). For collaborations with community organizations to occur, the two ministries would need to support relationships between BC’s health authorities and academic institutions to share funding, management and human resources that collectively serve similar interests. Perhaps this may pave the way for provincial educational infrastructure in the acute care field to improve the support for nurses’ PD needs.   Implementing a commitment to learner-centered foci, equitable resource accessibility and optimizing the workplace environments reflect a supportive organization that would ultimately reshape the vision, mission and role in supporting ongoing PD management. For instance, an organization’s embodiment of valuing learner-centered PD would mean nursing education within a facility would be informed by the needs of its staff, rather than solely based on the unit or organization’s overall needs. The consequence of a health care system that accepts accountability for its role in nursing CPD would require better education supports. Such responsibility requires a reorganization of health human resources and an increased investment in training and hiring nurse educators or professional practice liaisons in health care facilities to coordinate and manage nurses’ individualized PD needs and plans (Foley-Brinza & Brunges, 2015). Although this is an expensive investment, such initiatives have potential to build capacity, facilitate sustainability and quality of PD and career satisfaction for nurses in the workplace (Black & Farmer, 2013).  CONTINUING PROFESSIONAL DEVELOPMENT  63  Using the lenses of adult learning theory and relational inquiry would require adjustment of the mechanism for delivering PD (Arthurs et al., 2018). Arthurs and colleagues used the forces of Magnetism® to embody andragogy principles, transformational leadership, and multi-level coordination to critically examine how nursing excellence is enacted within their facility. However, it is important to consider the operationalization costs to such a model in BC’s context. The available PD activities would need to expand and evolve, both within and outside the workplace. This may involve using critical and transparent discussions with various stakeholders in health care and education to inform how CPD is currently understood, and where ought the links be made to improve the quality and access of PD. This would need to be done with consideration of the context of each acute care facility and the overall BC health care infrastructure. This implication of re-evaluating PD delivery in BC also requires nursing leaders who would inspire innovation, participation, and both intra- and inter-disciplinary engagement through using learning techniques that nurses would find relevant. Leadership and management teams would also be a part of the CPD conversation with their frontline nurses, as well as executive management to ensure CPD stays part of the overall agenda. Shepherd and Harris (2016) used andragogical principles to shape their educational framework and found positive outcomes on their facility’s learning culture, satisfaction and strong participation in nurses’ learning activities. Ultimately, nursing educators and leaders would need to coordinate with their organizational and community allies to accommodate nurses across all career trajectories and their respective geographical areas of work to ensure they can facilitate equitable PD opportunities. The Nursing Policy Secretariat has already identified that BC has many remote communities that employ nurses from all levels of experience who have shown a need for more  CONTINUING PROFESSIONAL DEVELOPMENT  64 educational supports and opportunities for accessing more resources, being included in the provincial community, and a commitment to a learner-centered philosophy (Byres, 2018).  Nursing Leadership. Implementing a vision and mission by leadership and management with CPD integration, commitments to a sense of community and learner-centered foci within the organizations would require a culture shift at the organizational and systemic levels. For example, it would be important to re-assess who is involved in the organization’s decision-making process, how do decisions occur, the functionality of current organizational leadership and management styles, and if BC’s society can collectively buy into the notion of CPD being a priority. It is up to those working within the domain of nursing leadership to demonstrate the links to all stakeholders, including the public and nurses, why having nurses positioned with tools and means to improving their practice for quality patient care through CPD serves everyone’s agenda.   Rewarding and recognizing nurses is a large influence in fostering a positive workplace environment (Fleischman et al., 2011; Johnson et al., 2011; Race & Skees, 2010). Aside from the positive effects on staff retention and employee satisfaction, the implication of recognizing nurses for their professional activities could invite them to pursue careers in nursing leadership (Brunges & Foley-Brinza, 2014). For example, Schulman (2008) and Tindale (2005) both suggested that hiring nurses in positions of leadership based on nurses’ CPD involvement, rather than practice experience alone, would encourage nurses to engage in CPD and pursue positions in leadership. Organizations that hire nurses into leadership positions recognize nurses’ CPD endeavors and reward their commitments to PD can have powerful impacts for nurses as well as nursing leadership. These hiring practices could ensure appropriately trained and educated nurse leaders are equipped with the skills and motivation to mentor and inspire others, in addition to  CONTINUING PROFESSIONAL DEVELOPMENT  65 incorporating the nursing voice into the overall organization’s operations. Furthermore, hiring these nursing leaders into positions of influence will shape organizations’ strategic plans to include support of nurses’ CPD.  There are huge implications for the nursing leadership domain if organizations were to employ formal nursing leaders: from advance practice (AP) positions, executive leadership, or even PD liaisons. These nursing leaders are advocates for PD resources, and are also mentors for junior nurses. In fact, they are also perfectly positioned to be knowledge brokers for stakeholders, community allies, and provincial and national policy representatives who may not understand nursing matters and needs (Drake & Berg, 2009; Elliott et al, 2013; Reno et al., 2005). This implication is especially important because each stakeholder impacts the processes and outcomes of their unique environment; which is especially true of larger centers which have varying factors influencing their respective organizations. LeClerc, Doyon, Gravelle, Hall, and Roussel (2008) explain the consequences of implementing a collaborative model that used AP supports within their dynamic environment: “Nurses who identified learning needs related to physical assessment, leadership and communication skills were provided with education. Nurses in AP roles (APNs2), as well as managers, role-modeled conflict resolution strategies and helped nurses…deal with reactions to change,” (p. 72). This provided nurses with professional autonomy and accountability to be supported and nurtured in a meaningful way for all parties involved.                                                          2 I want to acknowledge that the way I conceptualize Advance Practice Nurses differs from the national framework the CNA (2008) has outlined. Although I agree with most of this framework, for the purpose of this SPAR project, I do not limit the title APN to exclusively depict a Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP). Rather, I want to highlight the advanced educational preparation (i.e.: graduate studies), expertise, and scholarly work that APNs can deliver in positions such as Clinical Nurse Educators, Nurse Scientists, and Nurse Researchers (Acorn & Osborene, 2013; Cehic, 2017a).   CONTINUING PROFESSIONAL DEVELOPMENT  66  Furthermore, creating dual roles between academia and practice indicates tremendous potential and consequences for the nursing leadership domain. To illustrate, these partnerships could nurture relationships between academic institutions and acute care facilities for student practicums, as well as expand mentorship opportunities for students and nurses alike. Meanwhile, hospital nurses could benefit from accessing Schools of Nursing’ courses and lab sessions3, build leadership skills, and promote their capacity and spirit of inquiry for their CPD journeys (Elliott et al., 2013; Hinic, Kowalski, & Silverstein, 2017; McSherry, Cottis, Rapson, & Stringer, 2015). Another implication of using dual roles would mean nursing leaders could bridge the theory-practice gap by offering alternative perspectives to current bedside practices or evidence-based care (Doane & Varcoe, 2005). If nursing leadership can facilitate connections amongst community health care stakeholders with likeminded goals, the potential to utilize and manage the allocation of educational resources can be huge (Byres, 2018; Murray & James, 2012).   Other promising implications for the nursing leadership domain would involve nurses from all levels of practice to be engaged in a shared governance (Arthurs et al., 2017; BCCNA, 2016; Lewis et al., 2005; Race & Skees, 2010). Shared governance can impact nurses’ leadership skills, improve their political savviness, and promote empowerment to advocate for their needs. When leadership capacity and social capital is encouraged, nurses may feel more confident to share their thoughts, propose solutions and have a sense of accountability to their facility by being a part of the change (Soo Young, 2017). Shared governance is a participatory process that aligns with the operationalization of CASs, allowing all its agents to self-organize based on their                                                         3 Unfortunately, there are issues and challenges associated with actualizing such benefits from this partnership (for example, the shortage of nursing educators and faculty) (Nardi & Gyurko, 2013). Although such issues must be acknowledged, the scope of this SPAR project does not allow for such analysis.   CONTINUING PROFESSIONAL DEVELOPMENT  67 own needs; a process that allowed for increased nurse autonomy and engagement. Since the use of transformational leadership can help foster autonomy and empowerment in nurses, organizations can benefit from using it concurrently with shared governance concurrently for the many benefits to be actualized (Fischer, 2016; Keane, 2017). Rather than telling, selling or consulting nurses about an idea or decision, transformative leaders delegate decision-making to autonomous and accountable professionals with the guidance of their leaders (Ellis & Abbott, 2013). Rowe and Hogarth (2005) caution that “it will also mean higher levels of uncertainty, responsibility, decision-making and risk management” (p. 404). As such, issues like nurses’ workload and levels of burnout must be assessed and addressed in order for the benefits of this leadership style to be actualized. Senior and executive leaders must inspire confidence in their workers, trust their decision-making and encourage a CPD atmosphere in order for such a leadership style to be successfully utilized. Using shared governance concurrently with transformational leadership ultimately paves the way for a continuously inquisitive atmosphere within an organization, moulding a culture for continuous change based on real-time organizational needs (Bamford-Wade & Moss, 2010). These implications for nursing leadership could only be possible with simultaneous improvements in staffing ratios, healthier workplace culture, and the rest of the supports highlighted in chapter three.   Nursing Clinical Practice. Once leadership is established to support CPD through nursing education, then clinical practice will shift accordingly. The main goal for nurses is to provide their patients safe, professional, quality, and evidence-based care (CNA, 2018b). Each Canadian has a legal and moral right to equitable access nursing care in times of need (Government of Canada, 2018). When nurses engage in CPD, they can ensure they are doing their due diligence in providing excellent care regardless of their area of practice. The findings  CONTINUING PROFESSIONAL DEVELOPMENT  68 are embedded within themes that implicate clinical nursing practice in a variety of ways.   If a sense of community and equitable resource distribution are adopted within the mindsets of health care, government, and educational sectors, more PD opportunities could be provided to nurses through an intersectoral sharing of resources and nursing expertise. As a result, nurses would have a chance to improve specific aspects of their practice by having an array of opportunities to choose from in relation to their personal learning needs. Increasing the collaboration and communication of resources between, for instance, universities and health authorities, can potentially reduce the overall financial and labor costs of implementing these CPD resources (NECBC, 2011). Collaboration with community partners helps with scale economics and could reduce the time it takes for APNs or other human resources to facilitate PD opportunities (Bernardo, Valls, & Casadesus, 2012). If geographically or financially disadvantaged acute care centres collaborated with health authorities, hospitals and academia, these partnerships could provide a platform to share challenges, improve CPD capacity, and eliminate gatekeepers of PD resources. Specifically, this collaboration would allow remote and cost constrained centres to use existing supports rather than spending money on a PD opportunity that already exists. If this were actualized, regardless of where nurses are employed, the means for PD would theoretically be improved. For this reason, nurses in all areas of BC would have an improved chance of keeping up with practice updates, improving their knowledge and spirit of inquiry as it relates to their needs, as well as the needs of the population they serve.    A nurse’s CPD engagement requires accountability to one’s practice, “which means they must maintain and continuously enhance the knowledge, skills, attitude and judgment required to meet client needs in an evolving health-care system” (CNA, 2018b, para. 4). The implication of organizations investing in supports for nurses’ CPD extends beyond better patient care. It could  CONTINUING PROFESSIONAL DEVELOPMENT  69 also potentially diminish bullying and improve retention of staff in acute care (Breau & Rhéaume, 2014; Logan & Michael Malone, 2018). Organizational investments in CPD could be achieved through instilling a sense of teamwork, inclusivity, positive workplace environment and PD into nurses’ full-time equivalents. Currently organizations have difficulties retaining sufficient nursing staff to provide patient care, sick time and vacation relief; let alone to provide paid relief for nurses to engage in PD (BC Nurses’ Union, 2018). Nurses usually have to do PD activities during their personal time, and often do not get adjusted off their shifts to do PD due to cost constraints and nursing shortages (Coventry et al., 2015). In the current socio-economic environment, for organizations to provide nurses paid PD leave while still having relief nurses to cover patient care is not feasible. The implication of addressing the barriers of staffing, bullying, and lack of community or teamwork may improve circumstances for organizations to foster a sufficiently staffed workplace environment that is conducive for nurses’ engagement with CPD (BCCNA, 2016). This engagement can be heightened by including workplace PD programs that use a learner-centered philosophy. If nurses have PD incorporated into their day-to-day workday, the dynamics of how CPD could serve nurses’ practice would completely change.   In my experience, I have had shifts where I wished I could have stepped away from the bedside to reflect on the knowledge or skill gaps in my care delivery in order to improve my patient care. The implication of engaging in CPD during my personal time was also challenging due to the difficulties outlined in this scoping review (such as encroachment on personal boundaries and time). The implication of me seeking mentorship, PD opportunities, and funding for my endeavors resulted in me needing to make a choice between how I will allocate my time to practice, education, and my personal life. I subsequently left my full-time position to pursue PD, which ultimately affected my practice environment since another nursing position had  CONTINUING PROFESSIONAL DEVELOPMENT  70 become vacant. Had I been offered circumstances that were flexible to my learning needs, or had my CPD integrated into my practice setting, I would have stayed with my organization. Addressing these organizational supports and barriers would allow nurses to learn contextually relevant skills in relation to their practice, as well as their short and long term professional goals.   Nursing Research. The implications for nursing practice, education and leadership are all based on themes derived from primarily expert opinions, single site descriptive case reports, qualitative studies, or theoretical underpinnings. Unfortunately, the implication of having limited empirical evidence to sufficiently support and corroborate findings from this scoping review means stakeholders will be less likely to implement these findings. However, there is plenty of methodologically appropriate level two evidence that have laid a foundation to explore the connection of CPD with patient outcomes and patient care (Polit & Beck, 2014). This type of nursing research could especially yield informative results to all health care stakeholders, especially nurses, for how CPD can be optimized.   The implication of not having sufficient nursing research on CPD in the BC context would mean decision-makers would not have evidence to support the implementation of the various strategies that I propose in my recommendations. Research is a necessary step in order to give policy-makers and funders evidence and justification to ‘surrender’ their transactional leadership style in their current management of health care. Only then could policy-makers rationalize using shared governance and transformational leadership, and finally esteem nurses in a higher regard by sharing their power to influence policies and nurses means for engaging in CPD. The implication of these findings at least can give governments, academic institutions, and other nursing professional organizations reasons to sponsor bursaries for nursing leaders who specifically show interest in conducting research in this area of work.    CONTINUING PROFESSIONAL DEVELOPMENT  71  Since nursing research is meant to enhance nursing knowledge through finding trustworthy evidence in relation to an issue, these findings have several implications to consider within the research domain (Polit & Beck, 2014). A current state analysis needs to be conducted in BC before any research funding can be allocated to exploring how CPD can be supported at the structural level. This past winter, the CNA (2018c) hired a third party to conduct a survey on national nursing CPD engagement, and it would be greatly beneficial to do the same in BC to guide praxis. Even though I have presented information for why CPD engagement is an issue in BC, this needs to be measured in order to validate the need for further examination.   The intent of my research question was exploratory in order to inform practical directions to advance the nursing profession. As such, sound conceptual and operational definitions are required to be able to measure CPD in research studies to provide future knowledge acquisition with a solid foundation (Thorne, 2005). Measurement or survey tools are also needed to be able to quantity the systemic impact on nurses’ agency for meaningful CPD participation. Engaging in qualitative research to conceptualize CPD within the BC context is crucial prior to engaging in empirical research related to CPD in the organizational context is needed to test this research question in BC’s acute care facilities.   Recommendations   Within my scoping review, several noteworthy strategies have been used by acute care organizations to overcome barriers and implement supports related to nurses’ CPD. These strategies have either been ‘tested’ or surveyed by specific acute care settings like hospitals or inpatient tertiary care centres (Arthurs et al., 2018; Barnsteiner et al., 2010; Beal et al., 2008; Chan et al., 2011; Drake & Berg, 2009; Elliott et al., 2013; Eizenberg, 2010; Ferguson-Paré et al., 2010; Fleischman et al., 2011; Gould et al., 2004; Gould et al., 2007; Hockenberry et al.,  CONTINUING PROFESSIONAL DEVELOPMENT  72 2009; Johnson et al., 2011; Katsikitis et al., 2013; Lewis et al., 2005; Lynch & Happel 2008a; Lynch & Happel 2008b; McCormack & Slater, 2006; Mensik et al., 2017; Mick, 2011; Parsons & Cornett, 2011; Paterson et al., 2010; Steaban et al., 2003; Reno et al., 2005; Strickland & O’Leary-Kelley, 2009; Wittmann-Price et al., 2013), or have been suggested by reputable and key field experts (such as the RNAO, NECBC, NLN, and CFAT). Since my findings are not all based on empirical data results, I cannot confidently generalize their applicability in BC. However, the various recommendations that I offer to acute care organizations and their stakeholders in BC are based on the themes that surfaced from my findings, my collective practice experiences, and my overall critical analysis through the lenses of relational inquiry, adult learning theory and complex adaptive systems theory. These theories have collectively provided me a focus to select strategies that highlight the strengths found in building relationships in communities, sharing power, and emancipating the nursing profession to provide best practice in their patient care. For these reasons, I am offering a combination of recommendations that come directly from my findings, analysis, implications, as well as my own experiences.   Macro level. The dynamics amongst BC’s nursing regulatory body, the nurses’ union and nurses’ professional association have been controversial for several decades. Each organization serves their own purpose: “unions support the nurse and improve working conditions; regulators serve and protect the public; professional associations advance the profession and improve health,” (CNA, 2018d, p. 7). PD has evolved to being under the professional association’s agenda. Duncan, Thorne, and Rodney (2015) discussed the strides the CRNBC has made in the last decade by accepting the Association of RNs of BC nurses’ (ARNBC) as a complementary body in public safety. Unfortunately, the ARNBC and the BC  CONTINUING PROFESSIONAL DEVELOPMENT  73 Nurses Union (BCNU) have different perspectives about which organization is best positioned to advance the profession and health. These disagreements have resulted in lawsuits and incivility (ARNBC, n.d.). Recently the ARNBC has evolved into an association that represents all nursing entities (Nurses and Nurse Practitioners of BC [NNPBC]), with CRNBC following suit this autumn. I echo Byres’ (2018) recommendation that this intra-professional momentum for collaboration resumes with BC’s third pillar, the BCNU, to demonstrate to our stakeholders that these pillars are interdependent in supporting the delivery of quality nursing care. In the analysis and implications, the relationships and associations between workplace environments, professional development and patient care was discussed. If teamwork improves amongst the BCNU, CRNBC and NNPBC, then perhaps these powerhouses could help ensure their respective policies do not contradict or obstruct one another. Furthermore, their collaboration could also encourage strong communication to foster support for each other’s progress.  Unfortunately, collaboration between BCNU and NNPBC is not feasible in the near future considering their current incivilities. In order to move forward as a profession, these respective organizations need to adjust their mandates and policies by engaging in a negotiation of interests and values (Skelton-Green, Shamian, & Villeneuve, 2014). Policy directs decision-making processes and guides action. Engaging in policy matters is a professional obligation, and I recommend that these two organizations use the policy cycle framework4 to help reach a resolution: starting by “getting to the policy agenda” (p. 92). A steering committee needs to help mediate these organizations to engage in this process, further identify the problem, and consider what will happen to the nursing profession if it is not addressed. Once clarified, the BCNU and                                                         4 Skelton-Green et al. (2014) used Tarlov’s (2000) policy cycle that involves an eight-step process in how to proceed with policy change. Please note, this chapter does not describe the cycle beyond step 3.   CONTINUING PROFESSIONAL DEVELOPMENT  74 the NNPBC need to collect information, analyze their options and do their research. This policy cycle framework is a sequential process, but is at risk at becoming stagnant if key stakeholders are not involved. To help reach an agreement, individual nurses need to hold our union and professional association accountable to their mandates. Once civility is reached, nurses and the nursing profession will be equipped with leaders at the structural level to move their agenda forward in supporting CPD, amongst other professional interests.   Next, the NNPBC must improve communication with its nurses regarding how they can support them professionally. I have noticed a lack of understanding amongst my peers regarding NNPBC’s scope of support, and instead, these same peers frequently look to other provinces’ professional association for guidance. Once the NNPBC is established as an organization in the coming months, I recommend that their priorities include providing a clear explanation and guiding framework of what CPD is to BC’s nurses, and ensure it is equipped to provide nursing leaders the resources they need to support CPD for nurses. Most importantly, the NNPBC needs to advocate to the public on behalf of nurses regarding what it is we do, and how systemic supports for ongoing CPD is an endeavour that is also in the public’s interest to support.   Partnerships at the macro level could include other specialty associations and key stakeholders as well. For instance, the CASN and NECBC organizations have an incredible collection of experts. They could include their support of nurses’ CPD in their mandate by and explicitly including lifelong learning, and also use their established networks and communication channels to collaborate with other stakeholders like the NNPBC. In addition, it is timely for a collaboration to occur between the Health Employers Association of BC (HEABC), the Nurses’ Bargaining Association Acute, and BCNU. It is important that the currently proposed provincial collective agreement revisions address article 35; to include an equitable agreement regarding  CONTINUING PROFESSIONAL DEVELOPMENT  75 professional and staff development that ensures continuing maintenance of competence is reflected as well (BCNU, 2006).  Next, I propose testing a Clinical Academic-Practice Partnerships model used by Jeffries and colleagues (2013). Although this model was conceptualized for student nurses, the underlying principles can benefit education and CPD for nurses. “[Such] strategic alliances involve the sharing of resources to achieve mutually relevant benefits and they are flexible ways to access resources outside of one’s own institution,” (Murray & James, 2012, e17). This recommendation has stemmed from the implication discussion for nursing leadership domain. An APN working in a dual role between clinical and academic institutions could help bridge clinical nurses to resources only otherwise made available in academia for students. However, the suggestion of clinical academic-practice partnership is particularly fitting for nurses who want to engage in work-based PD offerings, and for nurses specifically interested in developing their careers in the education domain. Or, it can be an excellent opportunity to get mentorship, education and training for nurses who are interested in developing or improving their clinical education skills and preceptor abilities. Finally, it could increase collegiality amongst education, leadership and practice domains based on local community needs.  Lastly, nursing leadership in urban facilities should reach out to rural facilities to share fiscal, physical and health human resources dedicated to PD. Perhaps these relationships can begin by creating alliances with other health authorities’ education departments. I also recommend that nursing researchers reproduce Ferguson-Paré and colleagues’ (2010) study that examined partnerships between rural and urban hospitals while evaluating their impact on nurses’ CPD. However, based on the study’s limitations and pitfalls, its replication should be attempted only with hospitals that have stable and sufficient nursing staff; or, wait until nursing  CONTINUING PROFESSIONAL DEVELOPMENT  76 recruitment and retention improve in BC.   Evaluations at the structural level also can help provide insight to how CPD can be supported by systemic policies and infrastructures (Williams, 2010). Research at this level is especially important, because there is very little literature about current health care system structures and how its management impacts outcomes (Greenwald, 2017). I recommend further investigation and analysis to be conducted regarding how the current health care system and regionalization of BC’s health authorities impact the various fiscal and health human resources designated for conducting continuing education and CPD in acute care.   Lastly, based on the implications discussed for the nursing research domain, I recommend conducting an anonymous and third-party survey of BC nurses’ perceptions about what affects their CPD engagement; similar to the survey CNA had outsourced this past year (CNAc, 2018). I suggest including questions related to perceptions of influences from stakeholders at all levels of influence, such as the federal and provincial governments, the three pillars, their workplaces, and themselves. This survey could help provide insight into the associations between the current health care structure and how nurses engage in CPD; and perhaps, offer future directions for where the focus ought to be for policy reform. Meso level. I propose an evaluation and, if required, a reform of organizational management within acute care settings. This practice ought to be a part of each facility’s strategic planning cycle, especially since the dynamics within acute care settings are constantly changing. This includes population needs, staffing needs and resource allocation. Through the use of a relational worldview, health human resource planning ought to be based on a needs-based framework that considers evaluation results towards creating an iterative, widespread multilayered approach in workforce planning (Tomblin Murphy et al., 2012). These authors  CONTINUING PROFESSIONAL DEVELOPMENT  77 suggest that a needs-based approach should coordinate efforts to reduce attrition from the workforce, improve retention, train and educate new nurses, reduce nurse absenteeism and increase RN productivity. To complement this framework, I also recommend employing an 80/20 model, a health human resource strategy (Beal et al., 2008; RNAO, 2009). This model allows for 20% of a senior/experienced nurse’s full-time equivalent to be spent engaging in CPD activities, while the other 80% is spent giving direct care. Bournes and Ferguson-Paré (2007) suggested that incorporating this model helped with retention, reduced overtime and also provided higher patient satisfaction. The common denominator in nurturing work-based PD is having sufficient nursing staff and resources, which is why I urge health human resource planning and staffing to be a highly prioritized strategy to support nurses in their CPD endeavors.   Organizations also need to develop and evolve to meet their employees’ needs. For this reason, I recommend organizations that have strengths (such as in a certain area of expertise, or access to unique resources) to share their opportunities with other acute care facilities who still have areas for growth and need support. To achieve this, one mechanism could be for organizations to engage in the RNAO’s Best Practice Spotlight Organization (BPSO) program (n.d.a.). Once a facility is recognized as a BPSO, they can provide mentorship to other aspiring organizations. Another cost-effective strategy I recommend is for an organization to use Magnet® forces as a framework in creating an organizational culture that strives for nursing excellence. This may not necessarily entail the pursuit of Magnet® status because it is an expensive designation (Drake & Berg, 2009). One of the Magnet® foci is for an organization to commit to nurturing nurses’ CPD (Platts, 2018).  I specifically suggest implementing in-house professional practice development initiatives. An example that I personally found empowering as a nurse was engaging in a Corporate Nursing Clinical Practice Committee (CNCPC) (The  CONTINUING PROFESSIONAL DEVELOPMENT  78 Ottawa Hospital, 2017). This committee connected nurses from each unit across all campuses of the organization on a monthly basis to lead grassroots projects that could improve professional practice in the hospital. The hospital provided compensation, and participating nurses were required to disseminate CNCPC’s monthly progress to unit councils and front-line staff. This conversation connected nurses working at all levels across the facility, while it improved professional practice and simultaneously supported CPD of the nurses involved.   I also recommend that hospitals ensure they have a medium for disseminating CPD opportunities available in the facility itself, in the community, and those available through information technology. Likewise, being a partner in nursing excellence with the greater community is also important. As such, acute care centres need to share the same opportunities with their allies. I suggest each organization has a Professional Practice department (PPD) and committee to achieve this particularly key function (Barnsteiner et al, 2010; Fleischman et al., 2011). These PPDs need sufficient APNs or nursing leaders in permanent, full-time equivalent positions who are trained to coordinate successful mentorship programs, able to guide nurses in their CPD goals and plans, coordinate resources, and be an active member of nursing CPD journeys.   Organizations that show commitment to a learner-centered approach, while also encouraging nurses to get involved in PD activities, are immense supports to nurses’ CPD endeavors (Beal et al., 2003; Black & Farmer, 2013; Chan et al., 2011; Fleischman et al.; Gould et al., 2007; Race & Skees, 2010; Strickland & O’Leary-Kelley, 2009; Tindale, 2005; Williams, 2010). As such, I recommend that APNs who work in PD roles should proactively reach out to staff nurses to start PD planning and goal setting, rather than waiting for nurses to seek their support. Nurses at all levels (including those in formal leadership and management positions)  CONTINUING PROFESSIONAL DEVELOPMENT  79 need to be utilized for their skills and strengths to support one another in strategic partnerships (Steaban et al., 2003).   In order to support nurses in all areas of practice, I propose that organizational PD leaders utilize an Australian Clinical Supervision mentorship framework (Black & Farmer, 2013). This is a formalized partnership between two health care professionals, in which during work time, they support each other in professional practice, emotional support, and time for reflection. “Clinical supervision has the potential to help nurses reconceptualize [their] position in relation to the need for critical review of [their] care and decision[s],” (Dilworth, Higgins, Parker, Kelly, & Turner, 2013, p. 28). Formalizing the mentoring partnership can improve accountability to one another. To be effectively executed, clinical supervision should be consistently practiced, the unit should be sufficiently staffed, ensure it occurs while on duty, and have supportive managers and PPDs. I also recommend that these APNs who work in a CPD coordinator role should consult nursing informaticians (NIs) to help bridge PD resources to their organization’s nurses. NIs can be especially helpful in rural settings that have limited in-person PD activities. For example, 10 years ago, an American group of NIs started an online community platform for nurses across the world to share ideas and best practice (DuLong & Gassert, 2008). They aimed to, “create educational resources and affordable programs within the practice setting that foster information technology innovation and adoption… [and also] use the informatics competencies, theories, research, and practice examples throughout staff development and continuing education programs,” (p. 60). With relational consciousness, NI’s can be especially useful in identifying PD activities for nurses working nights, weekends, or part time; giving these staff flexible options by using technology like Blackboard, webinars, online discussion forums, and online  CONTINUING PROFESSIONAL DEVELOPMENT  80 library access (Blackboard Learn, n.d.). PPDs have potential to be excellent resources in supporting CPD for nurses at all levels.  Organizations need to ensure they employ nurses in positions of leadership and management as well as in roles related to supporting CPD (Drake & Berg, 2009; Reno et al., 2005). For this reason, I recommend that there is nursing representation at executive as well as middle management levels of acute care facilities. This is especially important because these leaders would be positioned to support nursing practice and education at the micro and meso level through utilizing their unique vantage point. Particularly, if CPD has not yet become engrained into the organizational culture, they can bring awareness to any gaps that require attention.  Finally, I recommend that leadership and management engage in specific strategies to help optimize workplace environments. Offering recognition and rewards were frequently noted in the literature (Fleischman et al., 2011; Johnson et al., 2011; Race & Skees, 2010). I propose that organizations coordinate staff appreciation and recognition awards, with a component that allows for nursing professional networking with those working within and outside the facility; especially because BC nurses reported appreciating professional networks for the support they provided in their CPD (ARNBC, 2012). I also suggest that leadership and managers engage with their nursing staff on a regular frequency to dialogue about their career and professional goals. From personal experience, when leadership engaged in informal or formal conversations with me, it often left me feeling inspired to pursue focused PD by means of thought-provoking questions. It facilitated reflection and goal-setting, connections to organizational liaisons, and perhaps even see how my PD endeavors could be incorporated into the unit processes.   CONTINUING PROFESSIONAL DEVELOPMENT  81  Micro level. As nurses, we must hold our leaders accountable in providing the means and resources for us to engage in CPD. However, this accountability begins with ourselves. I recommend for nurses to approach their professional practice with self-awareness and take action by challenging any barriers that prevent them from providing quality care – directly or indirectly. Annually, the CRNBC mandates us to engage in a reflection of our needs and self-assess our practice (CRNBC, 2018b). I recommend nurses use this information and seek support or mentorship if we encounter uncertainty or barriers for actualizing our professional goals. Within our workplace environment, we must communicate with our colleagues, our managers, and explore how this leadership and our overall organization can support our CPD. If resources are not available, we should request them.    Beyond our organization, we need to reach out to the NNPBC and CNA. Since these organization’s mandates are specifically situated to support nurses’ PD, they are ideally positioned to collaborate with nurses to share our needs and requests for PD guidance and support. If nurses do not authentically engage in their own CPD process, these organizations will not know how they can help us be better professionals.   Lastly, I recommend for all nurses (including student nurses) to learn how to be politically involved with health, education, and public policies. It is part of our duty as professionals, and bearing a relational consciousness in mind, we must remember and acknowledge that these policy domains impact the nursing profession and the conditions in which we work – no matter how remote they may seem (Skelton-Green et al., 2014). It is our responsibility as a profession to be part of the solution  There is an abundance of recommendations and strategies that can be offered to stakeholders for their consideration. The macro, meso and micro levels must concurrently work  CONTINUING PROFESSIONAL DEVELOPMENT  82 together to nurture the conditions nurses need to develop their professional standards, practices and goals. Conclusion  My curiosity as a nurse has led me to pursue CPD in several domains and by using various means. The clinical leadership in my organizations offered me encouragement and opportunities to push my professional boundaries. However, this was not always the case. Based on my experiences and the data I found in my background search, nurses’ participation in CPD has become more and more difficult due to organizational conditions and systemic constraints. I wondered what organizational barriers and supports existed for nurses to meet their CPD obligations, specifically in acute care settings. I used a scoping review methodology to develop a complete understanding of what the available literature and experts had to say regarding this problem, as well as concepts from several theoretical frameworks (adult learning theory, complex adaptive systems theory and relational inquiry) to inform numerous interdependent and important themes.   The accountability nurses have to the public in maintaining their professional competence is not an independent venture. Nurses’ management, organizations, community allies and governments all need to share the responsibility through developing a sense of community, a vision and mission by the leadership and management, commit to learner-centered foci, equitable resource allocation, and finally, optimizing the workplace environment. These five themes warrant application by BC’s health care and education stakeholders. 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Journal of Nursing Management, 18(6), 624-632. doi:10.1111/j.1365-2834.2010.01141.x Wittmann-Price, R., Celia, L., & Dunn, R. (2013). Successful implementation of evidence-based nursing practice: The indispensable role of staff development. Journal for Nurses in Professional Development, 29(4), 202-204. doi:10.1097/NND.0b013e31829b2212    CONTINUING PROFESSIONAL DEVELOPMENT 101 Appendix   Table of Findings                                                  1 USA = United States of America  Author(s) Year  Title Country (+/- State, Province) Type of Article * = selected via snowball or grey literature Purpose Findings Takeaway  Strengths and/or Limitations 1 Registered Nurses’ Association of Ontario (RNAO) (n.d.)  Best Practice Spotlight Organiza-tion (BPSOs).  Canada (ON) Web page*  To describe what are BPSOs and how it helps support the nursing profession.  BPSOs are selected health-care and academic organizations that have partnered with RNAO to implement and evaluate the RNAO's best practice guidelines over a three-year period.  It is a global program that is supported through resource toolkits and links with other BPSO mentoring organizations to help build up one another’s capacities in excellence.  1. Mentorship is not limited to an individual level, but also for organizations as a whole.  2. Using a professional nursing association as a support system and their publications can be a resource for organizations to utilize in supporting nurses in professional practice.  No data available on webpage to demonstrate efficacy of BPSOs.  2 Steaban, R., Fudge, M., Leutgens, W., & Wells, N. 2003 The Vanderbilt Professional Nursing Practice Program, Part 3.  USA1 (TN) Descriptive case report To review this facility’s professional nursing practice program and describe its outcomes. - A three-year project, four levels for nurses to aspire to across an entire continuum of experiences in hospital.  - Every nurse undergoes an annual 360 evaluation (self, peers, manager) over a period of time to ensure consistency of evaluation findings.  - This program is a tool to help 1. Evaluation and review process to allow the leadership team to be aware of nurses’ professional practice development needs, by keeping a review process simple and streamlined.   2. Consistent expectations of nurses across the Purely descriptive and no references used.   Extremely labour intensive, therefore in practice may    CONTINUING PROFESSIONAL DEVELOPMENT 102                                                  2 UK = United Kingdom 3 ROI = Return on Investment nurses plan for growth and development and engage in a formal process for its activity. With advancement, compensation follows suit.  - As nurses advance, their performance is reviewed by a committee made up of senior and middle management and nurses are interviewed by said committee.  - When nurses want to pursue advancement from one level to the next, resources are available in practice areas with access to contact the program liaison person.  - This assessment and evaluation method proved to be inefficient: labour intensive (2hr/week for meetings) and slow – particularly the interviewing process with all involved committee members - Also cost more for levels 3 and 4 (1% increase to budget)  organizations in relation to professional practice, as well as equitable opportunity for all nurses to pursue their CPD goals.   3. Model encouraged mentorship, reward and recognition.   4. It helped reframe future strategic directions and informed a transformational leadership style that resulted in a professional development culture.  not be feasible for many centres.  3 Gould, D., Kelly, D., White, I., & Glen, S.   2004 The impact of commis-sioning processes on the delivery of continuing professional education UK2 Qual- itative, exploratory study. - They sought to explore what the impact of commissioning health care education. Via purposeful sampling for interviews and - Need a detailed training needs analysis done, ensuring relevant CPD activities are offered, need a ROI3  to demonstrate the value of CPD activities, need improved communication between stakeholders (university and practice area and who will do TNA) as no one shows up to 1. Must have multi-stakeholder involvement when decisions are made about PD opportunities for nurses in the institutions.  2. Validation of PD activities chosen are needed (for it to be financially sound 1.Unclear which members had a nursing background to give these interviews validity.      CONTINUING PROFESSIONAL DEVELOPMENT 103 (CPE) for cancer and palliative care. focus groups.  - Senior management was interviewed (in the academic and practice settings).   modules. Ultimately needs to be learner-centered to address own CPE needs. -Have relevant coursework or training opportunities available in an accessible time frame (requesting what you as a nurse wants for 1.5 years in advance was too long). - University leadership voiced they didn’t see the need for them to spend time in classroom. - opinions found that those in higher leadership positions should not be solely the ones deciding what front line worker need in their curriculum – nurses must be consulted (learner-centered) - need formal and informal PD opportunities - lecturers had trouble keeping up with policy changes and clinical credibility was a barrier.  decision, both training needs analyses and ROIs need to be done).  3. Flexible, style, and accessible time frame for the learning activities.   4. Learner-centered CPE opportunities.    2. Also difficult to understand the logistics behind how commissioning occurs in UK to be able to suggest its applicability in BC, Canada. 4 RNAO 2004 Position Statement: Excellence in Clinical Nursing Practice Canada (ON) Position state-ment* For Ontario’s nursing association to articulate and summarize what is nursing excellence, who is responsible, what are the required conditions, and how can nursing excellence be - It is understood within RNAO that it is the collective responsibility across all levels of nursing profession and their affiliated organizations, including their workplace (nurses, their employers, government, academia, nursing associations)  - In particular, a nurse’s workplace supports nursing excellence by respecting their expertise, and has practice models Examples RNAO gave for workplaces to ensure sustainability of nursing excellence: 1. Support nurses in practice area certification;  2. Have opportunities available at the workplace for professional education and development such as resources, best practice guideline use, information databases and sharing of knowledge.       CONTINUING PROFESSIONAL DEVELOPMENT 104 supported.  that allow them to work within their scope of expertise  - Workplaces must have leadership, education and administrative supports in place to help support nursing staff’s continuing education and decision making - Workplaces need to support nurses across all levels of experience (student to expert) through using preceptorship and mentorship programs as well as nursing leadership programs and training  - Lastly, an organizational culture is needed that has commitment to a spirit of inquiry and caring for its patients through caring for its staff’s well-being.  - Acknowledges all domains of nursing are equally valuable.  3. Implementing rewards and recognition of nurses’ work  4. Mentorship and preceptorship facilitation by organizations for nurses at all levels.   Nurses’ workplaces have a large role in ensuring they aren’t creating obstacles for nursing excellence to be actualized.   5 Lewis, T., et al.  2005 The Methodist Hospital CCU: A Beacon Unit of Excellence.  USA (TX) Case report To describe this hospital’s journey of getting the Beacon Award (requiring success in excellence within elements that include PD support - like education, The professional nursing practice infrastructure includes a shared governance model, the Nursing Clinical Career Progression Model (NCCPM), and the Center for Professional Excellence (CPE) office. - Nurses are part of decision making at both local and organizational levels. - Nursing leadership council is comprised of nursing senior 1. Shared governance models in organizations are aligned with being inclusive of nurses’ PD needs and agendas.   2. Having various professional domain committees gives a variety of opportunities for nurses to engage in activities that are pertinent to their learning 1. In isolation, this case report is not transferable or generalizable.  2. Did not disclose actual costs.  3. Aside from the award, no report on nurse outcomes of    CONTINUING PROFESSIONAL DEVELOPMENT 105 training, and mentoring and ethical organizational).  leadership and HR representative and have five sub-councils that include councils for Research and Education, the Clinical Practice, and the Quality and Performance Improvement. - Nursing Clinical Career Progression Model (The five levels in the model are clinical apprentice, clinical colleague, clinical mentor, clinical leader, and APN) for all domains of nursing - CPD activities are offered through the CPE office, while the state government allowed a grant covering all costs for nurses returning to school like tuition, books, childcare, transportation, tutoring, and paid leave for school. This grant also was provided for successful certification. - The CPE office also provides programs for specialized training with class and practical training for nurses to become a resources nurse on  - The NCCPM also supports nurses in keeping a portfolio of their work (resume, samples of work or PD activities, and personal anecdote reflections). needs.   3. State grant was extended to compensate nurses to pay for all associated indirect costs of engaging in PD (like childcare, transportation, resource access, etc.)  4. Nurses are supported to maintain a portfolio through their workplace – to either improve in current practice area or are given the tools/skills to pursue different areas of nursing in the facility.   this program.   6 Reno, K., Cerone, P., Ferket, K., Wojcieszak, E., & 2005 Getting over the rainbow: One community USA  (IL) Descriptive review To describe how their community hospital has employed How they enacted their vision:  - Investing in nursing care by employing APNs and Clinical resource nurses to mentor other nurses and providing clinical Facilitators: 1) Learner-centered, looked at all their generations and levels of experience to give opportunities for PD. (ex: Descriptive therefore non-transferable, and limited references.     CONTINUING PROFESSIONAL DEVELOPMENT 106 Reshoft, M.  hospital’s vision. strategies to support quality nursing care through investments in their HHR.  nurses with resources for staff.  - Annually, ten mid-career nurses can bridge to bachelors through local university.  - 18-month residency program for new grads.  - Hospital offered a program for all shift workers to improve professional skills such as computer skills, public speaking, navigating e-resources.  - Also, facility changed the professional practice model to provide nurses more autonomy, allowing to work in full scope.  - Shared governance was revamped to ensure nurses from all levels (bedside to corporate) were involved.  Improve redundancy/efficiency to allow nurses to embody professional practice at work by having automation.   invested in a new graduate residence program to help this nursing population feel professionally competent to work within full scope).   2) Collaborate with community stakeholders (colleges, universities) to provide external PD opportunities.  3) Improve informal PD through investment of APNs and other nurses in senior leadership positions.   4) Shared Governance model was also useful in this context.   7 Tindale, R. 2005 Board’s eye view.  UK Commentary To describe conditions needed for nurses to provide quality care. - Need to invest in people (NHS started that through ‘Leading an Empowered Organisation’ program and ‘Clinical Leadership Program”) rather than solely promoting people into higher positions based on years of experience  - Organizations need to leverage their employees’ enthusiasms and ideas through education by using facilitators like leadership programs 1. Organization’s must collaborate with employees.   2. Offer in-house resources and opportunities for training and/or leadership involvement for senior leadership programs and base employment in such positions to be based on PD involvement rather than seniority. Author is in senior leadership position at her hospital in which she is employed.    CONTINUING PROFESSIONAL DEVELOPMENT 107 8 McCormack, B. & Slater, P. 2006 An evaluation of the role of the clinical education facilitator.  UK Explor-atory qual-itative To explore if a Clinical Education Facilitator (CEF) (whose role was to assess nurses’ needs for and run programs of clinical education) made a difference in nurses’ learning experiences in the hospital setting.  CEF’s are also known as clinical nurse educators, staff development educators, practice educators - but in this context it is an organizational /senior nursing leadership role.   - The CEF role in isolation was insufficient to maintain all the needs required to coordinate CPD in an organization, and CEFs were not sufficiently supported to meet their role’s duties.  - Clinical nurses, and especially those with least seniority, felt there was a poorer organizational culture for learning opportunities and supports than those in higher positions - posing the question if the CNF’s role and scope was visible, used to its full scope or misused at a higher corporate level based on other complementary findings.   1. Multiple supports need to be simultaneously in place in order for success to be actualized in supporting nurses in engaging in PD effectively.   2. Visibility of available resources to front line was not as obvious, affecting their ability to be used by the front-line nurses.  1.Disorganized report of findings.   2. One facility’s case report, not generalizable.  9 Gould, D., Drey, N. & Berridge, E.J. 2007 Nurses’ experiences of CPD. UK Descriptive review* To explore nurses’ experience with CPD by presenting partial results from a larger study that enabled or discouraged its use.   Study information: 28% of qualified nurses discussed their CPD an analysis was done on these specific responses.  A big finding was that the sort of CPD available isn’t suitable for all nurses, chosen content isn’t relevant for everyone, and too much focus on making learning a ‘credit’, voiced hands-on practical experience was most needed, and it shouldn’t encroach on personal time.  1. CPD needs to be learner centered 2. CPD needs to be encouraged by senior management 3. Need a variety of CPD activities and sources available to nurses 4. CPD opportunities need to occur during work time and not during personal time 5. Working part time and night shift was a barrier in having equal opportunities All data came from one area in London and was taken out of context of a larger study.    CONTINUING PROFESSIONAL DEVELOPMENT 108  • n = 471  • 3 acute centres in London • participants worked >3 years in these centres Organizational issues: not enough staff to backfill gap in workforce, education sessions are cancelled due to poor turnouts, policies don’t work in reality “only good in writing”(p.606), unsupportive management due to feeling threatened, and even nursing management felt like they can’t work on CPD because of work commitments (i.e.: lack of opportunity). for work-based CPD.  10 Beal, J., Riley, J., & Lancaster, D. 2008 Essential Elements of an Optimal Clinical Practice Environ-ment USA (MA) Descrip-tive qual-itative  From the perspective of nurses in 3 hospitals, this article’s purpose is to explore these nurses’ perceived supports and barriers for an optimal practice environment where scholarly nursing practice can flourish.  Study information:  n = 36 purposeful recruitment of nurses that had received awards, or Major outcome was that these nurses’ workplaces that had a good balance of PD and patient care was one that had an optimal clinical practice environment.   Across all participants, it was viewed that CPD needs to be embedded into daily practice and allow (as one nurse was quoted) ‘‘…room for thinking about problems in a different way, coming to different solutions that may have better outcomes,’’ (p.490).   They reference the 80/20 model “model in which nurses spend 80% of their salaried time in direct patient care and 20% on PD that includes focused mentorship, time for reflective practice, and education about patient-centered care”  1. Position statements need to be lived and acted upon – not merely just written on paper. This needs to occur at all levels of the organization – particularly at the executive leadership level.   2. CPD needs to be embedded into daily practice  3. Daily successes and failures are seen as learning opportunities and encouraging bringing such areas for improvement forward is in line with an optimal practice environment   4. Need to leverage the internal motivation of staff with external supports of time for CPD and mentors for CPD activities.  1. From 3 tertiary medical centres, and 1 community centre (two hospitals had Magnet“ designation).   2. Did not have a wide variety of clinical nurse opinions, only interviewed those who were already motivated for engaging in CPD.     CONTINUING PROFESSIONAL DEVELOPMENT 109 earner highest clinical status.   Themes that emerged:  1) There are explicit statements that the hospital embraces CPD for nurses, but implicitly they don’t feel like the hospital values it because of insufficient resources 2) No support with time and expertise to engage in activities, despite the internal motivation being present → barrier. They want mentors.  3) Not just belief, but action from management (encouragement and challenging staff to push themselves)... needs to come from the top executive team so unit managers are supported when their time is spent on empowering their front line. Consistency in organization. 4) Mistakes seen as PD opportunities, non-punitive environment  11 Canadian Council on Learning 2008 State of Learning in Canada: Toward a Learning Future. Canada Report* A Canadian current state analysis of learning, reviewing how to best implement a life-long learning culture.  - Adult learning is not linear, with complex pathways and life events impacting abilities to learn - Barriers such as learning program designs, financial costs, rigid schedule and structures, unclear expectations, lack of previous experience acknowledgement, and poor employer supports have been described as a limiter to adult participation in learning - PLAR (Prior Learning Assessment and Evaluation) is a 1. Must create and/or offer opportunities that are have flexible schedules and structures, must be financially accessible, and have supportive employers for what the learner wants  2. Assessment and evaluation of the individual is required to make learning more learner-centered and meaningful  Canadian non-profit corporation that uses evidence-based information regarding learning across the lifespan. Funded by the federal government.     CONTINUING PROFESSIONAL DEVELOPMENT 110 tool that has been used in health sciences that applies informal learning achievements as credits towards other programs. PLAR is understudied and underutilized - Challenges like workforce demographics, demands for higher productivity and fast advances in technologies  - To have success in learning, must have a balance in success at home, community and educational endeavours for learners to be successful in either of the three - Need flexibility in transitions from one area of work to the next - A culture change at a national level must occur, to value the learning that occurs at the adult level is also important and worthy of attention and support.  3. Need to acknowledge prior experiences and consider applying them as credits to future programs.   4. Introduce new technology and innovation with appropriate infrastructure to help its uptake by those who will use it.   5. Need to appreciate the learner as a person with unique circumstances, offer understanding and support to help them succeed with one another 12 Lynch, L. & Happell, B. 2008a Implementing clinical supervision: Part 1: laying the ground work.  Australia  Explor-atory, qual-itative In a rural mental health hospital, this study aimed to use interviews to explore and evaluate how clinical supervision (CS) is operationalized, as there are a lack of guidelines and frameworks to support its use.  - Five stages surfaced in implementation, and in the first two (in this paper) they surfaced a feeling of hostile cultures due to unique changes in the facility (private funding evolved to public funding) such as demotions and bullying.  Since the need for CS was needed, exploring how to go about it was done by senior leadership (looking at the current informal processes of CS, and collaborating with other facilities that are doing it well already)  - Changing the organizational 1. Fundamental organizational conditions are required before activities and programs that support CPD can be implemented  - i.e.: must diminish bullying and negative workplace conditions, and shift towards a positive workplace culture. 1. Not transferable/generalizable in isolation  2. Facility had unique circumstances.     CONTINUING PROFESSIONAL DEVELOPMENT 111  Study information: • n=7 • Purposive sampling culture that reflected a more positive, trusting leadership team, being selective of the right leader.  Then, providing CS training via coursework to nurses and supervisees. 13 Lynch, L. & Happell, B. 2008b Implementing clinical supervision: Part 2: implement-ation and beyond.  Australia Explor-atory, qual-itative  Same as above (#18) – continuation.  - Implementation stage consisted of creating a committee that supports CS by those who were interesting using a bottom-up strategy, they had created a strategic plan and discussed marketing to the organization. Clear structures in organization allowed them to support the initiative and having baseline data from staff needs assessment gave them credibility when presenting CS to the organization.  - CS was incorporated into the strategic plan  - “The estimated 80% of people initially negative and suspicious about clinical supervision was now estimated to be only 15–30%... increased sense of professionalism,” (p.69). - Funding was a barrier in sustaining the project for ongoing training of supervisors and other changes in organization causing change fatigue  - They also indicated evaluation of outcomes was key to justifying resources 1. Must be selective when introducing change in a facility as it can cause change fatigue.  2. Important to have an evaluation so you can show progress to all stakeholders who are involved.    1. This model was made iteratively and specific for this context, thus the steps and stages cannot be necessarily transferable.  14 Munro, K. 2008 CPD and UK Discursi A discussion of Literature found CPD activities 1. Need an agreement on This was a    CONTINUING PROFESSIONAL DEVELOPMENT 112 the charity paradigm: Interrelated individual, collective and organisational issues about CPD. ve paper and review focus on CPD requirements determined by both the nurse and their employers, and the potential mismatch between the two.  offered are only those relevant to the organizational needs rather than supporting CPD the nurse chooses. - Historically, barriers like work schedules, workplace demands, and tensions between the personal and organizational responsibilities have had a huge impact on access and will in engaging in CPD.  - Supports that they reviewed were “career progression, dedicated time and financial support,” (p. 958).  - offer suggestions for organizational supports like helping nurses create portfolios, learning needs assessments, informal and formal learning opportunities,  -Their ‘charity paradigm’ argument is that if supporting CPD is not part of the overarching strategic plan, it will appear like the organization is doing nurses a favour, rather than the patients, ultimately still undermining the nurse. values and beliefs from top down to bottom up and vice versa.  2. Key recommendation is for organizations to provide frameworks and structure to help CPD be goal oriented and purposeful, as well as having equitable opportunity for all nurses to access CPD rather than selective.  thoughtful critique of where the mismatch can occur and that collaboration is required amongst all levels of the organization and health care system.   15 RNAO 2008 Position Statement: Recruit-ment of Inter-nationally Educated Nurses (IEN).  Canada (ON) Position state-ment * A call for action to not actively recruit IENs, but to allow the opportunity for the decision to rest with the IEN who may choose Ontario - This position statement aims to clarify their position alignment with the International Council of Nurses to commit to advocating for permanent financial and systemic resources in supporting IENs in bridging their native training with Canada’s expectations.  1. Increase infrastructure for nursing education nationwide (educators, facilities, etc.)   2. Allocate ongoing funding for incorporating IENs who chose Canada as their new home. Not generalizable as source is an expert opinion.     CONTINUING PROFESSIONAL DEVELOPMENT 113 as their new home. RNAO advocates for supporting IENs to practice nursing locally.   - Rather than seek IENS, improve local HHR capacity  - Workplace health is seen an important factor for a healthy HHR pool.   3. Improve workplace practice conditions like safe workloads, professional opportunities and quality management.  16 Schulman, C.  2008 Strategies for Starting a Successful Evidence-Based Practice Program  USA (OR) Descriptive review  Purpose of this article is to describe mechanism for implementing an EBP program successfully into a facility.  - Ensuring nurses in facility are clear on what EBP through staff meetings, email/flyers, educational forums - To implement EBP, there is a need to have protected time and fiscal resources for nurses to engage in EBP, for nurses in all shifts - E-database access, librarian to teach nurses use on e-databases - Organizational practice model should allow EBP use in care, and also the use of EBP by a nurse should be considered for career promotions as evidence of quality professional care. 1. Ensure accessibility for all shift-workers, ensure know how to access all resources available to staff, by actively encouraging its use. This can be done through the organizational professional practice model of care, and communication of available opportunities - at an organization wide level.   2. Career advancement should be based on professional activities.  Author is a Clinical nurse specialist. 17 Buscher, A., Siversten, B., White, J.  2009 Nurses and Midwives: A force for health  Survey on the situation of nursing and midwifery in the Member States of the Denmark Report*    To report the 35 involved countries’ progress on their implementation of the Munich Declaration in 2000 using a survey conducted in these countries in 2009. They - More than half these countries do not have a workforce plan in place for health human resource planning.  - Since the last survey in 2004, professional associations have increased their activity and dedication to supporting nurses and midwives at a political level to improve these professions’ conditions.  - WHO advocates for supporting leadership development so nurses 1. A cultural shift: at the organizational and national level, there needs to be an understanding of the value and potential of the work nurses and midwives provide before the necessary funding for education can even be considered for allocation to these professions.   2. Nurses and midwives require strong regulatory and 1. Macro level influences in Europe may not be transferable to BC context.   2. Data was collectively for both nurses and midwives.     CONTINUING PROFESSIONAL DEVELOPMENT 114                                                  4 WHO - World Health Organization  European Region of WHO4. examined if the outlined principles and educational strategy were used or implemented using their  are skilled to contribute to all levels of policy and service delivery decision making  - Insufficient regulatory and legislative frameworks (ex: Germany, UK, Denmark, Switzerland), medically dominated health care systems (ex: UK, Sweden, France, Germany), financial resources (ex: UK, Sweden, France, Germany) were seen as major obstacles in nurses and midwives to work to their full potential.  - In 17 countries, professional status and public image of nurses and midwives is considered very low, and any advance in nursing practice is often used as delegation for medical function.  professional associations to support these professions’ agendas at the structural level.    18 Drake, E., & Berg, R. 2009 A Hospital's Journey Toward a PD Program. USA (CA) Case report  Description of a hospital that wanted to employ Magnet principles rather than the designation itself.  Aim was to change culture in facility to one that supports CPD activities.  - Their literature review prompted an internal analysis of their clinical ladder program. The intent of the program changed to one of encouraging PD and professional practice rather than one of a corporate agenda.  - They acknowledge nurses get caught up with tasks and forget their professional duties.  - They also acknowledged the multigenerational nature of their workforce, saw potential for synergy if used the skills and strengths from various generations 1. Nurses needed at executive level to embody and role model professional behaviours for other nurses in facility – need nurses in executive leadership positions.  2. Know your workforce and use its strengths to its advantage (i.e.: each generation in nursing has something to offer the other) – leading to next point:  1.Not a study, article was conceptually based - thus very limited applicability in other facilities.   2. Context of this program was poorly described.  3. No outcomes from    CONTINUING PROFESSIONAL DEVELOPMENT 115                                                  5 EBP – Evidence Based Practice as a mechanism within the clinical ladder program. - This revamped program provided coaching and examples of PD by embodying professional behaviours, offering free classes for research use, taught nurses leadership and administrative skills.  - This hospital included a CNS and CNE in their leadership team. - Used Theory of Change (Lewin): (1) unfreeze current behaviour (leverage those with most potential and those against the change, find out why and work with it); (2) incorporate a new way of doing things into a unit that was happy with status quo (i.e.: had little CPD offerings; (3) refreeze new culture by using the committee revamped the clinical ladder program to include expectations of people wanting to do this by actively engaging in PD activities (ex: student nurse mentorship, ACLS instructor, active member of associations, attending and disseminating meeting findings to staff) 3. Must allow opportunity for collaboration intra-professionally.   4. Requires an organizational culture that values CPD, which was supported by the next point:  5. Theoretical framework to guide organizational change was a helpful support.  changes in facility on their employed nurses were described in paper. 19 Hockenberry, M., Brown, T., Walden, M., & 2009 Teaching evidence-based practice USA (TX) Descrip-tive case report Describing implementation of a “EBP5 scholars program” that Those who finished the program applied their knowledge to revising policies with a Clinical Practice council, which was then approved by the Nursing 1. In-house education program allowed for greater engagement with the organization and helps shift organization to one with a 1. This was a one-off program, funded through the    CONTINUING PROFESSIONAL DEVELOPMENT 116 Barrera, P. skills in a hospital. was organized by this hospital’s “centre for research and EBP” (eight week lecture, workshop, and discussion program). Coordinating council (senior leadership execs). By having many people involved in this program, it created an organizational culture shift.  Outcomes: Influenced nurses’ leadership capacities, and advocacy for best care. Skills were taught to these front-line staff to help shape policies by those who use said policies.  positive culture.   research department, and may not be transferable to other settings  20 RNAO 2009 Strength-ening the Nursing Workforce for a Stronger Health Care System. Canada (ON) Briefing note * A review of the provincial government’s promises and issues that are impacting Ontario’s strength of their nursing workforce.  - Must ensure the promised 9000 nursing positions to reach safe nurse-patient ratios - Ensure 70% of nursing positions are full time positions to help with full integration with the nursing profession  -  Full time employment for new graduates after 6month post-graduate internship ends - Incorporate 80/20 program for full time and experienced nurses to spend 20% of their work time in mentorship and enhancing their PD activities (helping with retention, reduced overtime and higher patient satisfaction) - Reduce wage inequities amongst field of health care for nurses  1. At a systems level, there must be support for financial infrastructures to safe nurse-patient ratios, and value nurses from all levels of experience.  2. This needs to occur concurrently as these factors are interdependent for nurses to be positioned to have a strong health care system.   3. The findings from this briefing report are all foundational conditions needed to have professional development be nurtured   Ontario provincial government is different from BC’s, with different population dispersion and needs, although both BC and ON are embedded within the same national nursing legislature and regulation principles.  21 Strickland, R., & O’Leary-Kelley, C. 2009 Clinical nurse educators’ (CNE) perceptions USA (CA) Cross sectional survey To describe barriers in hospital settings for nurses to use EBP to develop practice – using - Those in Magnet facilities perceived less barriers to EBP than those in non-Magnet facilities - Of 29 items, nurse doesn’t have time at work to read research 1. Working in Magnet facilities is perceived as helpful in establishing an organizational climate for supporting professional development activity like Of the 122 CNEs, 1/3 worked in a Magnet hospital, and 8% worked in    CONTINUING PROFESSIONAL DEVELOPMENT 117 of research utilization. CNE perspective.  Study information:  • n=122 CNEs • Convenience sampling  • Used BARRIERS instrument (ranked as 4th top barrier), other staff are not supportive of implementation (11th), facilities are inadequate for implementation (17th), and 20th on list is administration will not allow implementation Facilitators: 74% of responses were related to colleague support, resources, funding and networking. 45% of the time was due to admin support and encouragement, and 16% to advance availability and access to research reports and resources EBP.   2. Workload and infrastructure were perceived to be barriers from CNEs’ perspectives.  for-profit hospital. 64% of CNEs were masters or doctorate prepared. 22 Webster-Wright, A. 2009 Refraining PD through understand-ing authentic professional learning. Australia Discour-sive analysis* To discuss various ways of achieving CPD in the workplace through conceptualizing CPD. - author critiques PD’s current conceptualization in both research and practice, and could perhaps be a cause for lack of PD changes across all professions - evidence says PD should be active, practice related and ongoing - PD vs PL, uses PL because PD is mixed in the literature as professional growth and formal PD courses (p. 705). - little literature available about differences of learning as an undergraduate professional vs continuous learning  - based on her literature review, she claims the experience of PL is needed to be understood to properly support it.   - there is impact of regulating PD, as learning is not always 1. The way PD is understood amongst various people, what it means, and its value is a barrier.   2. Professional learning is something to be embodied, and organizational supports need to be creative in how they facilitate this.  3. Must avoid a deficiency-based learning/development programs and embrace various means of learning.  4. An overarching spirit of inquiry is part of a supportive environment.  5. Need a framework or guideline for organizations 1. Author is a phenomenological doctor, focuses in inter-disciplinary continuing professional learning in workplaces.     CONTINUING PROFESSIONAL DEVELOPMENT 118 measurable, and suggests a framework can encourage transformative learning.  - if the belief that PD is skill-based vs reflective or self-evaluative, the conditions may not be fostered.  to follow to ensure they are cognizant of workplace conditions that nurture their professional’s PL.  23 Bamford-Wade, A. & Moss, C.  2010 Transformational leadership and shared governance: an action study. New Zealand Descrip-tive case report   Describes the journey of the paradigm shift in the 90’s  from the managerialism health reform to an action-based leadership process; a framework that supports nurses’ practice.  Used four domains for praxis in achieving transformational leadership combined with shared governance.     - Idealised influence, inspirational motivation, intellectual stimulation and individual consideration (p. 816).   Action processes used for their transformational change: upper management giving decision making power via shared governance (with teams within the governance, including leadership, practice, quality, PD and recognition, PD and research). Doubled funding opportunities for scholarships and education    Outcomes were: continuous learning for nurses, interprofessional collaboration and support/respect of one another rather (unlike horizontal violence that is seen elsewhere) 1. Nurses became politically capable by being involved in shared governance, resulting in empowerment.   2. Incorporating a values-based culture in this workplace context required action-based leadership.  3. Learner-centered organizations that use encouragement, recognition, and inspirational leadership.    Risk: they conceptualized transformational leadership to transfer ownership to those at the front-line - individualistic lens on nurses needing to take ownership for the environment in which they work, - ‘not very shared governance’ 24 Barnsteiner, J. H., Reeder, V. 2010 Promoting evidence-based USA (PA) Descrip-tive case report To illustrate the systemic processes This hospital acknowledges that in order for nurses to deliver excellent care, supporting nursing 1. Nurses get ‘release time’ to engage in research activities. Limited information provided    CONTINUING PROFESSIONAL DEVELOPMENT 119                                                  6 SoN – School of Nursing C., Palma, W. H., Preston, A. M., & Walton, M. K.  practice and translational research. needed to provide nurses with resources to implement EBP and knowledge translation at the bedside.    research and EBP must be a focused priority. This was done by having expert consultants, as well as allowing the opportunity for nurses to participate in scholarly activities  The infrastructure they implemented were as follows:  1) Hired a director of nursing translational research who is also a faculty with a SoN6, clinician educators, and nurse scientists. 2) Clinical Educators provide nurses mentorship for research, and hold positions in both the hospital and SoN 3) Nurse scientists volunteer a min of 10 hrs of consultation/mentorship and then in return get access to hospital data sources for their own research 4) Fellowship programs 5) Logistic supports: access to University library system, AV set up for meetings, software education, process supports (ex: librarian)  6) Knowledge Translation (KT) activity: nursing research committee does monthly grand rounds to frontline staff for both day and night shifts  7) Shared governance councils for various areas of nursing (Quality   2. There was a close collaboration between local schools of nursing and the acute care setting.   3. Sharing of resources between university and hospital to increase EBP use, conduct research and other CPD activities.   4. Fostering time and means for disseminating nursing research to nurses while being mindful of their shift-work hours.   5. Evaluation of activities to shape PD offerings.  6. Learner-centered: Hospital offered a variety of mechanisms for learning, allowing for learners to choose their method of engaging in CPD that is meaningful for them.  regarding the logistics and resources required for implementing these strategies, which further limits this case report’s general-izability.     CONTINUING PROFESSIONAL DEVELOPMENT 120 Practice, PD, stewardship, KT, etc.)   8) Organization collects nursing sensitive data to help inform development activities  9) Hospital invested in an evidence-based computer program that teaches skills using video, procedural checklists, tests, feedback, and other suggested learning materials.  25 Eizenberg, M. M. 2010 Implementation of evidence-based nursing practice: nurses’ personal and professional factors?  Israel Cross- sectional survey  Of the four research questions, one was “Is there an association between availability of system resources (the option of finding scientific material in the workplace and working with a computer) and EBNP implementation?” (p. 35).   Study information: • n=243  • Self-reported questionnaiAbout half of the participating nurses said the library was available for their use – a library primarily filled with medical journals, while it housed only 32% nursing journals.  41% did not have chance to use a computer, and 42% had no Internet access   In Northern Israeli context, no relationship was found between community nurses and hospital nurses use of EBNP.   -Study also demonstrated that organizational support plays the strongest role in advancing EBNP as per logistical regression. 1. EBNP usually occurred only where there were resources available in the workplace.   2. EBNP also occurred if nurses knew how to read professional literature and if their workplaces supported them.   3. Intra-professional collaboration was a source for knowledge acquisition.   1. Limited interpretation of results because 64% of nurses worked in hospitals, 28% in community, and 6% in nursing homes.  author is not a nurse, but lecturer of stats and research of health systems management     CONTINUING PROFESSIONAL DEVELOPMENT 121 re  26 Ferguson-Paré, M., Mallette, C., Zarins, B., McLeod, S., & Reuben, K. 2010 Collabora-tion to Change the Landscape of Nursing: A Journey between Urban and Remote Practice Settings.  Canada (ON) Descrip-tive qual-itative   A pilot project of 37 nurses that are part of the UHN (Uni Health network) was done to test out a collaboration between urban and rural hospitals using a staffing model to help with retention and recruitment for all three sites. “It provided an opportunity to practice in new clinical settings and to engage in knowledge transfer experiences and PD initiatives,” (p.91). Urban employed nurses did 4-6 week placements in rural community hospitals. -A provincial ministry of health project, with support of the provincial nursing union was marketed to Ontario nurses. - - Approval from primary place of work was required for participation. - Travel & accommodation costs covered with isolation incentives. Psychological and physical supports provided in advance. Nurses from north had same experiences to come to Toronto and had PD activities (as well as interprofessional) organized to ensure their practice was safe. Rural hospital leadership received training on web-based staffing tool. - This project allowed knowledge exchange intra-professionally, exposed nurses to other areas of nursing in the province, stimulated enrolment into graduate studies. PD in cultural sensitivity, primary care nursing skills, working in full professional scopes, sharing of e-learning resource access (ex: courses) through the UHN to the northern hospitals that previously didn’t have this resource.   - Northern hospital reported a cost savings in overtime. 1. Collaboration between university and acute care centres helped support PD activities for their nurses, to upkeep competencies as well as helping with retention and overtime usage.   2. A well rounded support system needs to be in place for nurses for a project that is situated around such a lifestyle change (physical, emotional, psychological).    1. Local staffing needs didn’t always allow managers to let their nurses leave to the affiliated northern hospital.  2. Need a certain number of baseline staffing to allow such a collaboration to successfully be implemented.   27 Paterson, 2010 Educating Australia Comm- To describe Part of professional practice is to 1. Must improve intra- Did not    CONTINUING PROFESSIONAL DEVELOPMENT 122 K., Henderson, A., & Trivella, A. for leadership: A programme designed to build a responsive health care culture. entary on a case report how and why continuing development of nurses needs to occur progressively. nurture development of other nurses as well, a philosophy that is within a transformational leadership style. Used a large teaching and research hospital in Australia created a leadership program that has various stages available for nurses with various leadership experiences of nurses.  It is a sequential program made up of workshops, reflections, and discussions, and the use of organizational environment for learning opportunities (i.e.: PD in day to day practice). They also have done formative and summative evaluations. professional leadership capacities across all levels of experience and across the organization to empower nurses for attain the CPD activities they need.   2. Evaluations of CPD for nurses in workplace.  3. Use practice-based scenarios and experiences to inform CPD.    describe in detail the logistics of running such a program, nor the outcomes for this case study used in the commentary. 28 Race, T. K. & Skees, J. 2010 Changing tides: Improving outcomes through mentorship on all levels of nursing. USA Dis-course paper Based on the premise that mentorship can improve PD, empowerment in nurses, etc., this article addresses several important issues around this topic - one of which are organizational challenges in achieving mentorship at all levels. They provide Organizational barriers: nursing turnover, shortages, retirement all deterring attention away from focusing on improvement mentorship but authors argue that despite the latter, organizations must try and change organizational culture to advocate for nurses to autonomously practice, be part of a form of shared governance, continued learning and supporting inter and intra-professional relationships.  - Also citing the importance of senior leadership support, incentives, nurse appreciation/recognition, schedule flexibility, remove workplace bullying, establish mentorship 1. The profession of nursing and its underpinning philosophies require a transformational leadership style and supportive workplace culture, and as such, will naturally help propel mentorship to flourish.  2. With transformational leadership style, a combination of flexibility, positive workplace environment, shared governance, recognition of nurses’ accomplishments and endeavours all complement fostering CPD 1. Not a primary source of information – limited transferability.    CONTINUING PROFESSIONAL DEVELOPMENT 123 strategies for nurturing mentorship. programs, and a mentorship coordinator in the acute care setting.  29 Williams, C. 2010 Understand-ing the essential elements of work-based learning and its relevance to everyday clinical practice. UK Critical review To review the literature on work-based learning, clarify its significance in practice improvements, and how to develop such programs.    - Work based learning in this context is understood as experiential, student and organization-centered, learning is everybody’s business. It can serve an outcome to do the job competently, or to create change in the workplace.  - It has been used in development plans coordinated with practice-educators. By doing this, it can be more achievable and mutually beneficial.  - Review found the transformative kind of workplace learning has been seen used for senior nurses almost exclusively. Work-based learning gives more meaning to the nurse. Learning is the entire organization’s business: those that are supportive of a learning culture are “non-hierarchical, team-based learning structures, empower change, involve staff and open to innovation” (p. 627).  - Everyone within an organization needs to be engaged in learning activities, and even leadership’s neutrality to the idea is a barrier to the supportive environment. Releasing staff to engage in work-based learning is barrier, risking patient care being affected.  1. Nurses, if given the chance to collaborate with their organization, can direct their CPD activities to develop both themselves and their organizations.   2. Leadership needs to actively make time for development of their staff, facilitate their PD.   3. Facilitation of work-based learning needs to be proceeded with training for the facilitators.  4.  Transformational leadership limits the control senior leadership can have   5. Empowering staff has potential to paradoxically decrease work-based learning – if nurses end up seeking activities outside the workplace.   6. Evaluations of organizations are key to understand needs, and instil a culture of change to be okay (due to the potential outcomes of work-based Although an excellent review, limited data on her methodology process.     CONTINUING PROFESSIONAL DEVELOPMENT 124 learning) 30 Chan, G. K., Barnason, S., Dakin, C. L., Gillespie, G., Kamienski, M. C., Stapleton, S., Williams, J., Juarez, A., & Li, S.  2011 Barriers and perceived needs for understanding and using research among emergency nurses  USA (CA) Cross section-al survey   To examine survey findings of nurses’ perceptions of the individual and organizational barriers for doing and implementing research.   This survey assessed five domains:  “(1) nurses’ research values, skills, experience, and awareness; (2) organizational settings’ opportunities, barriers, and limitations to research; (3) nurse understanding and comprehension of research and evidence; (4) presentation and accessibility of research; and (5) continuing Statistical findings from survey:  - 23% had trouble with KT, -33% difficulty analysing data,  - 37% conducting research studies,  - ¾ had trouble getting funding. - 69% felt approaching administrators for project support resources or approval was a barrier, - ~ 1/2 the respondents lacked familiarity with review boards, knowledge on sampling techniques and which sort of study to use. - Despite these findings, ⅓ presented in presentations or were part of a research team - nurses felt an increase to pay should be based on activities like participating in research activities (62.0%), sought nursing research residency programs (61.9%), and requested paid time (i.e.: protected time) away from patient care delivery to conduct research (59.4%)  - Discussion of shared governance as strategy to help with this.   1.Research resources are needed to support nurses’ competence   2. Health care organizations are dynamic and require a well-rounded approach that includes mentorship, education, time for research activities, encouragement from executive leadership, multidisciplinary involvement, and financial compensation or awards.  3.6% response rate   6.5% were not nurses (paramedics/medical technicians in ED)  36% worked for a Magnet hospital (therefore mixed views of what organizational barriers are present), and 75% worked in non-profit hospital  Survey did not capture opinions of nurses who are not part of the association. This could omit the perspective of  accessibility to research engagement.     CONTINUING PROFESSIONAL DEVELOPMENT 125 educational topics to improve knowledge of the research process,” (p. 26).  Study information:  (n=978) of eligible emergency nurses association members 31 Fleischman, R. K., Meyer, L. & Watson, C. 2011 Best Practices in Creating a Culture of Certifi-cation. USA (OR) Case reports descriptive review.  A best practice review for how to encourage certification by looking at three hospital’s experiences. It describes themes that emerged amongst professional and organization’s discussions at a roundtable presentation.   The five themes were: Commitment to excellence; Supportive and encouraging environment; Setting a Goal and goal-directed evaluations; Available educational resources; and celebrating and rewarding excellence (Table 2, p.34).  - 1st Hospital: A curriculum and class format program was created by the CNS that is knowledge beyond the baseline requirements of working on the unit, and CPD credits are given with completion all ran by a cardiac education committee made up of various credentials (bedside certified nurses, masters prepared nurses, etc.). Financial compensation for the exam is given upon passing, and acknowledgement of 1.Celebrate nurses’ achievements and efforts.  2.Reward successful PD milestones.   3.Interdepartmental collaboration allows resources to be maximised.   4. Senior leadership involvement in encouraging and facilitating educational committees, prioritizing it as valuable to the hospitals.  Authors did not disclose if these facilities were for profit or public, therefore the feasibility of transferability of strategies may not be readily applicable to the BC context.    CONTINUING PROFESSIONAL DEVELOPMENT 126 certification is done at a hospital wide during ‘national certification week’ and certification increased from 1 nurse to 28% of nurses being certified - 2nd Hospital: Another med/surg critical care unit increased certification of their RNs from 7 to 35%. Senior leadership created a campaigning team to get nurses motivated, as well as interdepartmental collaboration (educational department and library service) sponsored an in-house CCRN review course (in addition the CNS organizing a unit wide weekly 2hr course for 8 weeks), celebrating the achievements, and a financial award 32 Johnson, J. E., Billingsley, M., Crichlow, T., & Ferrell, E. 2011 Professional develop-ment for nurses: Mentoring along the u-shaped curve.   USA (NJ) Descrip-tive case report Describing a Magnet hospital’s design of a mentorship program. Aim of paper is to describe their six-month Nurse-to-Nurse mentoring program “to develop professional knowledge of 5 domains of the facility: clinical - Volunteering their time (not compensated) - Just over a third of nurses have worked in the facility for less than 5 years, few in the middle between 5 and 15 years, and large numbers of experienced nurses with 15 or more years.”  - This program is unique because nurses are selected to develop their roles for specific in-house leadership positions.  - This program evolved from one that was originally a joint program for University student and the hospital  - Hospital realized they need to 1. Overt appreciation for the talent and experience of all generations of nurses in the facility was acknowledged and nurtured through the way of this thoughtful program implementation and operationalization.   2. Senior management also got support in PD.   3. Structured program with a mentor and mentee who were willing to engage in the process proved to be a good combination for success.  1. Data from focus groups was not shown to support the claims that was not shown to support the claims that this process was successful.   2. Financial and time resources were not disclosed.      CONTINUING PROFESSIONAL DEVELOPMENT 127 practice, informatics, education, research, and admin,” (p.122).  preserve the intellect of the experienced nurses - Clinical managers participate in a Sigma Theta Tau International web based educational curriculum on management (self-paced, flexible, structured) with quarterly meetings with director of hospital - Mentorship was not permitted with a subordinate to alleviate sense of conflict of interest  - Nurses who have worked at that hospital > one year could participate, and at the outset both parties learned the expectations required of each party.  - “The mentors meet with their mentees twice a month to discuss developmental goals, performance challenges, successes to celebrate, key learnings, positive opportunities for career advancement, and plans for follow-up. At the midpoint and the end of the 6-month experience, the mentors and mentees meet to discuss, debrief, and celebrate the program at a luncheon sponsored by the division of Nursing,” (p.122).   4. Celebration and recognition of successes was conducted.  33 Mick, J.  2011 Promoting clinical inquiry and  Evidence-Based Practice (EBP): The USA (TX) Descrip-tive case Report  Purpose was to leverage the individual motivation of wanting to use EBP by providing an A fun “Sacred Cow” (i.e.: a routine practice that is presumed as belief-based) contest based inspired 92 inpatient submissions - spearheaded by a nursing research council, with winners being selected for offering of EBP 1. Having organizations create a means for PD in a fun and good-humoured way can increase the engagement and motivation of PD and professional practice activities. 96% respondents were university prepared RNs    CONTINUING PROFESSIONAL DEVELOPMENT 128 Sacred Cow Contest Strategy.  organization wide strategy to support the activity  solutions, PICO elements, specific to nursing, etc. Follow up to the winners included support in addressing how to change the practice to be EB.     34 Moran, P., Duffield, C. M., Donoghue, J., Stasa, H., & Blay, N. 2011 Factors impacting on career progression for nurse executives. Australia Discursive paper What impacts career progression in nursing? Examining literature regarding progression into “senior leadership positions”. -Need formal mentorship programs. - Their review found having a workplace that has flexibility in hours, increasing rewards for antisocial shifts, or job share options may be helpful.  - Also in their lit review, authors found less nurses are likely to progress in careers in rural areas due to lack of opportunities for PD activities and limited leadership 1. Consider personal, work-related and professional factors, as well as location and mentorship availability and family friendly policies.   2. Must consider mechanisms for rural acute care settings to offer PD opportunities and resources that are usually only offered in urban settings.  Not empirical, but evidence-based discourse.  35 Nursing Education Council of British Columbia (NECBC) 2011 A Policy Framework for Nursing Education in British Columbia Canada (BC) Position frame-work* A guide to the political position and strategies of the NECBC.  Provides a framework to help nurses in BC succeed in providing professional and quality care through appropriate education infrastructures.  - They suggest this to be done by their use of their political voice to help influence policy on education and resources amongst their fellow stakeholders like the MoH and HAs.  -They particularly note to collaborate, and advocate for sharing of resources to ensure CPD occurs for all nurses across their career continuum.  1. Multi-stakeholder collaboration is perceived as needed to get action actualized.   2. Resource sharing is required in times of financial constraints.  Geographical location is advantageous in relation to research question.   36 Parsons, 2011 Sustaining USA Qual- Aim was to Facilitators: Embed a philosophy 1. Must have both financial Did not    CONTINUING PROFESSIONAL DEVELOPMENT 129 M., & Cornett, A.  the pivotal organizational outcome: Magnet recognition. itative study look at barriers and supports of sustaining Magnet status, surveying 15 Chief Nursing Officers in Magnet hospitals across the US.  within the executive management team for quality care, including investing in ‘intellectual capital of nurses through continuing development and education, nurses in leadership positions to support these infrastructures (Ex: director for professional nursing practice) as well as sharing leadership and transformational leadership styles in the senior management.  Barriers: financial insecurity, maintaining resources, turnover of senior leadership. and human health resources security dedicated for both direct CPD supports but also other principles.   indicate if it was a public or private facility, and only looked at senior leadership perspectives of organizational facilitators and barriers, which could give a narrow perspective 37 Elliott, D., Ugboma, D.,  Knight, J.  2013 Implement-ing a collab-orative framework for academic support for registered nurses UK Case report - project eval-uation They aimed to describe a collaboration between the NHS and academic institutions whose academic support framework was informed by a scoping review (for nurses to engage in formal CPD activities where they return to school). A 3 year project was aimed at maximizing the funding In keeping with relational framework, this study acknowledges the nurse as a person who has personal and professional duties and can need considerable support in achieving CPD. - They focused at multiple levels of praxis (individual and structural) - UK has a fund for continuing education of nurses and physicians in multidisciplinary contexts, and Health authorities connect nurses to this funding for formal study - Nurses are given an algorithm when registered with NHS to help them plan their CPD. (Called ‘Learning beyond registration’) - Tools and resources are given during times of common pitfalls 1. Academic staff working in the acute care settings, as well as having a CPD team was helpful to staff, as they were considered part of the team and not ‘outside consultants’.   2. Ensuring the project/initiative was iterative and flexible helped it be successful   3. Learner-centered resources.   4. National funding for specifically health professional’s CPD.   The algorithm was assumed successful and not formally evaluated.     CONTINUING PROFESSIONAL DEVELOPMENT 130 available to nurses for learning.  (ex: A liaison from academic institution would be at the workplace, academic support email to access 1:1 support for tutoring) - Resources were learner-centered (mix of online and in person supports, visuals and dialogue based, flexible) as a variety of resources went through a trial and error  38 Black, E. & F. Farmer   2013 A review of strategies to support the professional practice of specialist cancer nurses  Australia Descriptive editorial   Discussion of professional supports needed for nurses in specialty or advanced areas of acute care that would encourage PD or mitigate burnout.   They reference an Australian program for Oncology RNs to be supported at a policy level that requires workplace supports for maintaining capacity and professional practice standards.   Organizational supports are, for example: funding, CPD activities, mentorship, clinical supervision, debriefing, effective clinical leadership.   According to this national framework, mentorship programs should be formal, inclusive, flexible, participation should be a choice for both participants, facilitate CPD, be given sufficient resources for coordination of this relationship. - networking is used as a means for CPD supports, specifically, an organizational membership network (i.e.: an intra-professional/specialty group of 1. The root of all the supports is having the organization be flexibile and learner-centered, requiring having clinical  and executive leadership that is committed to supporting these strategies.   2. Networking events for various CPD activities or opportunities for engaging with other colleagues or finding mentors with likeminded interests has been suggested.   3. Need right foundations in place before supports like clinical supervision and mentorship can be successfully implemented to nurture PD.  1. They conceptualized CPD as I do in Chapter 1.   2. The framework is based on an individualist framework, using HCP as facilitators for self-care, and wants the workforce to be skill based rather than role based.   3. Although this article was evidence based, it was a mere summary of frameworks that exist in    CONTINUING PROFESSIONAL DEVELOPMENT 131 people, like acute care nurses)  - clinical supervision, in Australia, is “defined as ‘an exchange between practising professionals to enable the development of professional skills’ (Driscol, 2005),” but it has not been successfully implemented in a formal manner.  Australia that can support cancer specialty nurses 39 Katsikitis, M., McAllister, M., Sharman, R.,  Raith, L., Faithfull-Byrne, A., & Priaulx, R. 2013 CPD in nursing in Australia: Current awareness, practice and future directions.  Australia Descrip-tive study  To study the current and future needs of nurses and midwives in Australia regarding their perceived barriers or supports to engage in their required CPD activities.    Study information:  • N=289 • Participants were Enrolled Nurses, Registered Nurses, and Registered Midwives • Recruit-ment done - Since 2012, nurses and midwives were required to present a professional portfolio upon annual registration. - After a literature review, authors found barriers such as negative attitudes by managers, no time off given to attend, unable to backfill unit, inadequate notice of opportunities in advance to plan.   - 31% of publicly funded nurses and midwives said their CPD was paid for compared to 17% of private participants. - Almost ⅔ of respondents believed it was a shared responsibility to pay for CPD between them and their organizations.  -78% that their employer not paying for CPD didn’t influence them not participating, and rather it was encroachment on their personal time and understaffing - Rather, an explicit supportive culture and appreciation of nurses engaging in it mentality of organization towards CPD was 1.  It is a systemic barrier for these nurses and midwives where they didn’t know what is considered a CPD credit and needing to document of all of it  *regulation of CPD paradoxically poses a difficulty on the process itself.  2. Financial compensation in insolation is not enough  3. CPD activities encroaching on personal time is perceived as a barrier by these Australian nurses and midwives.  1.Midwives were a part of study as well,  and hospitals surveyed were both private and public (65% of survey respondents were from public sector)  and private sector.  2.They had studied mostly part time nurses while public sector employed more full-time nurses.      CONTINUING PROFESSIONAL DEVELOPMENT 132 in private and public hospitals in Australia • Paper and pencil survey perceived as a support, if organization sees it as a valuable activity then as will the nurses/midwives. 40 Wittmann-Price, R., Celia, L., & Dunn, R. 2013 Successful Implementation of Evidence-Based Nursing Practice USA Descriptive Case Report Description of a collaborative program development to support the facility’s newly appointed Magnet status.  - Interdisciplinary Research council and Nursing Research council merged, composed of team members from all levels of leadership (top to down).  - They surveyed nurses from 8 different units in their hospital to inform activities that ultimately contribute to the forces of magnetism (including EBP, education, QI projects, etc., all improving PD).  - IRC/NRC supported ground-up project ideas to improve knowledge-based work of nurses.  1. Activities that improve professional practice need facilitation by organizational structures whose explicit mandate is to support nurses in whichever specific professional practice endeavour is sought.  Short article and doesn’t use much evidence to base the organizational decision making for its EBP implementation process.   41 RNAO 2014 Submission to Health Canada’s Advisory Panel on Healthcare Innovation  Canada (ON)     White paper* RNAO aimed to clarify their perspective on what innovation for health care means and gave suggestions for how the federal government can help support healthcare innovation.  Their requests from federal government:  1.Comprehensive research to have data to support health policy through reinstating a long-form census  2) Advancing a health accord with concrete action for national standards for leadership in health care through suggestions like allowing nurses to work within their full scope with implementing 1. For nurses to have systemic support to be innovative and shaping health service (a form of PD activities), macro level policies at the federal level need to be re-evaluated and adjusted to include RNAOs reasonable requests.   2. National policies and priorities affect provincial ministries of health and thoughtful considerations This white paper does not directly address CPD, but the conditions in which they can occur.       CONTINUING PROFESSIONAL DEVELOPMENT 133 educational supports to coordinate this.  3) Embrace EBP due to its potential for financial and care efficiencies   RNAO warns the current system that is moving towards a dual-tierd system, user fees will threaten our health care system. Must resist infiltration of privatization as that is not a population centered viewpoint.    made in the new Health Accords must appreciate nurses’ capacities and pave supports for their success.  42 Coventry, T. H., Maslin-Prothero, S. E., & Smith, G. 2015 Organizational impact of nurse supply and workload on nurses CPD opportuni-ties: an integrative review. Australia Integra-tive review  To describe their integrative review of studies from Canada, China, Greece, Hong Kong, Jordan, the UK and Japan, on the impact of healthcare organizations' nursing supply and workload on their continuing professional development opportunities in acute care.   Study Three themes identified: a) Time: unable to participate during work hours because of inadequate staffing, nurse absenteeism, lack of coverage to fill in for patient care, 20% denied permission to go, unpredictable workloads, and insufficient time    b) CPD in personal time encroached on boundaries.   c) Organizational culture and leadership (managers don’t actively support nurses, limited opportunities available, perception of those in management feeling threatened and do not want to support the competition, inadequate funding) 1. Organizations need to set value on CPD, if they don’t – nurses too will limit their engagement in CPD   2. Expecting nurses to do CPD in personal time was a barrier.   3. Immediate patient care (workload) and safety is a priority when compared with nurturing the potential of optimal patient care through fostering CPD.   4. Workload and patient care was a barrier in accessing in-house training opportunities.  Strong source that used many research studies to inform their conclusions.     CONTINUING PROFESSIONAL DEVELOPMENT 134 information: • n = 11 43 BC Coalition of Nursing Associa-tions (BCCNA) 2016 Visioning health care in B.C. in 2026. Canada (BC) Policy forum report*  In 2016, representatives from BC’s union, regulatory colleges, students, health authorities, governments and nurses from each practicing stream discussed what health care could and should look like in ten years. In order to improve patient care and availability of health care services in BC, five themes emerged from the roundtable discussions. Of those five themes, two were: “1. Interprofessional collaboration must be present in all areas across the health care system; 2. System level issues in recruitment and retention must be addressed,” (p. 4).  For former, discussions included ensuring nurses need to be used to their full scope and full integration, ongoing support for competency maintenance, and shared governance and strong leadership is a way to help move these issues forward. The latter theme highlighted a need to retain health care providers in rural areas, and ensuring their CPD, skill maintenance and mentorship opportunities needed to be addressed through, “ideas …[such as] establishing a 24 hour buddy/mentor or utilizing sister hospitals as resources,” (p.12). Further, these strategies were linked to needing strong financial and non-monetary incentives, partnerships with academic and practice areas, diminishing workplace bullying, establish flexibility in staffing models.  1.  Support nurses simultaneously with monetary and non-monetary resources for better patient care by providing opportunities to maintain skills, engage in CPD using flexible staffing, mentorship and opportunity for use of full scope.   2. Community partnerships with academia and other centres to share expertise and resources.   3. Need to diminish workplace bullying.  Multi-stakeholder involvement in this policy reform: Registered Nurses, Licensed Practical Nurses, Nurse Practitioners, Registered Psychiatric Nurses, nursing students, and  representative from regulatory colleges. union, professional associations, health authorities and government (p. 3).     CONTINUING PROFESSIONAL DEVELOPMENT 135 44 Russell, J.,Hannan, M., & Carnegie foundation for the Advancement of Teaching. 2016 Building and supporting improvers.  USA Blog post * How network improvement communities (NICs) can improve teacher’s capacities through use of implementation science and BTEN.  - their framework is similar to Problem Based learning, and their program is very similar to mentorship programs in health care using implementation science and PDSA cycles.  - implementation science (such as using PDSA cycles) to help teachers use feedback process to improve the school’s context but also their teaching - principles of feedback process involves senior leadership, improvement facilitators, case managers and mentors to assess, evaluate and goal set with teachers.  - It involves: assessing and evaluating their workers; and giving supports; non-punitive.  - Each stakeholder has a unique contextual understanding in supporting the teacher (content, logistics, process, etc).  1. For teachers to be supported, collaboration across the entire organizations’ leadership team is coordinated.  2. There is an explicit and implicit value placed on improvement and development of capacity and skills by schools and this in itself is an active effort in helping these professionals.    3. Evaluation of CPD supports for teachers and the schools is also part of the NIC, constantly using feedback to improve and adjust based on current contexts.  1. Not for health care   2. Hours of work and time off for PD in summer is not relatable to acute care nurses  3. Funding differences  45 Shepherd, M., L., & Harris, M. L.  2016 Advancing a Magnet® culture in the midst of change.  USA (TX) Descriptive Review Examining how to address a barrier of changing HHR and other cultural changes while trying to re-certify for Magnet status.  They used andragogy principles to enhance capacity for recertification through helping nurses see relevance to their practice and profession (PBL activities), provide a workplace that is safe for learning and has resources, leverage staff’s expertise (did evaluations to see this), take readiness to engage/learn into consideration (by shared governance, revise professional practice models), and 1.Assessment and evaluation of an organization’s current status is critical in informing what activities are needed to be done at an organizational level to help instil a culture of nursing excellence using the 14 forces of Magnetism.   2. Using principles of adult learning theory as a framework for their activities, they were able to Although this hospital did maintain its designation for 12 years, it is unknown if this was effective in helping them maintain their designation.     CONTINUING PROFESSIONAL DEVELOPMENT 136                                                  7 PD = Professional development ensured entire organization knew the Magnet values to help embody the complementary behaviours to support nursing excellence.  create strategies unique to their facility.  46 Mensik, J.S. Martin, D. M., Johnson, K. L., Clark, C. M., & Trifanoff, C. M. 2017 Embedding a Professional Practice Model Across a System.   USA (AZ) Case report - post intervention survey  Purpose of paper was to describe initiatives a hospital went through to embed a PD culture in their facility.  Study information: n=982 nurses  Organizational supports were underpinned by a nursing professional practice model, and this model was explicitly discussed in nursing position descriptions, employee orientations, the philosophy is in line with nursing professional standards (ethical practice, equitable care, EBP, etc), intra-professional peer review of poor practice patterns in a positive manner, a system wide shared leadership council (similar to shared governance). - Survey yielded a culture of predominantly professional practice as present in the facility at all levels of nursing (front-line to senior leadership). 1. Strong organizational culture was required for supporting CPD activities.   2. Using a professional practice model within the strategic plan can support CPD.   3. Nursing leadership at all levels are key in ensuring this model is enacted accordingly.  No baseline assessment provided prior to all the interventions to see if inferences could be made 47  Arthurs, K., Bell-Gordon, C., Chalupa, B., Rose, A. L., Martinez, D., Watson, J. A., & Bernard, D. 2018 A culture of nursing excellence: A comm- unity hospital’s journey from Pathway to ExcellenceUSA (TX) Descrip-tive case report  To describe the strategy one community hospital used (Pathway to Excellence“ to Magnet“) to achieve nursing excellence.  Their focus was on PD7 for nurses, safe work environments and a shift to include components of a Magnet model. (Ex: transformational leadership, structural empowerment through the use of interprofessional shared governance; supporting innovation and improvement projects; grand rounds; online 1. This organization accepted a global professional practice model to support PD, practice standards, financial stewardship, shared governance, EBP, research and innovation.  2. This journey required 1. This article described how to change an institution’s commitment to a nursing excellent culture, not how to sustain it.     CONTINUING PROFESSIONAL DEVELOPMENT 137 P. “ to Magnet“ recognition. journal club)   Logistically, they incorporated: - flexible scheduling, tuition reimbursement, a clinical career pathway for professional advancement of nurses - certification support via offering on-site review courses - executive leadership visibility and transformative style adoption (executive and nursing leadership attended workshops to learn how to execute the latter) - Magnet coordinator was the facilitator of implementing magnet model (used Andragogy framework) - article referenced an ADKAR model (p. 28) for working on organizational changes (: awareness, desire, knowledge, ability, and reinforcement) coordinated vision, strategic planning, transformational leadership styles, and commitment to organizational change.   3. Systemic understanding and accountability to nursing excellence as an organization.  2. Did not describe if it was privately or publicly funded hospital.   3. Limited information about costs of implementing the change to inform feasibility of applying such strategies in other contexts.  48 Byres, D. 2018 Nursing Policy Secretariat Priority Recommendations Canada (BC) Report * To present preliminary findings and provide recommendations for inform British Columbia’s provincial strategy in optimizing the use of nurses.  - Nurses wanted to engage in CPD but noted financial barriers, unable to get time off work due to their workplace’s nursing staff shortages  - The supports that are in place for nurses (like Nurse Educators) do not have time to support front-line nurses with coaching or mentorship due to other demands  - Many nurses felt unprepared for entry to practice and felt little support from their organizations.  - Current staffing models not Many takeaways included in report such as:  1. Education models and continuing education practices need to be re-examined by governments, academia, professional and other stakeholders (ex: interdisciplinary education models, clinical learning units, specialty training at undergraduate level, etc.)  2. Must evaluate current 1. This data is embedded from a [local] provincial context and is therefore particularly relevant.  2. It is for all sectors of nursing, not    CONTINUING PROFESSIONAL DEVELOPMENT 138 conducive for workplace needs; retention and recruitment is an issue – with little understanding of staffing models by many key stakeholders - A lack of support services exist for nurses to access expertise in nursing practice  - A lack of senior leadership at the structural levels of health authorities does not help nurses have a voice in their domains of practice in their organizations  staffing models and implement new strategies, particularly for rural areas of nursing practice.   3. Create and support positions of nursing leadership in executive levels of organizations and government to highlight needs of nursing profession  just acute care.  49 Carnegie Foundation for the Advancement of Teaching. 2018 Building a Teaching Effective-ness Network (BTEN) USA Web Page * Purpose of BTEN is to bring together leaders in education practice, policy, and research to improve the development and retention of effective teachers in US schools (many were novice teachers and needed support). - Program funded by the Gates Foundation. - This network is made up of US organizations: American Federation of Teachers (AFT), the Institute for Healthcare Improvement and the Carnegie Foundation and two large public school districts. - it’s a framework for regular and quality feedback to inform development of beginner teachers with coaching from principle or other appointed mentors  1. Collaboration, evaluation and coaching of teachers by workplace mentors is considered fundamental.   1. Program is funded by a private donor.   2. Program incorporates the time off in the summer, a differing schedule than the nursing profession.  50 National  League for Nursing (NLN)  2018 Profession-al Develop-ment programs: Overview USA Web Page * The purpose of NLN is to offer PD and other teaching resources for nurse educators.  - the goal through these sources is for all participants and field experts to collaborate and exchange expertise.  - partnerships are with practice 1. Intra-professional collaboration is needed for knowledge sharing and exchange.   2. NLN also recommends A privately funded organization that requires membership for accessing    CONTINUING PROFESSIONAL DEVELOPMENT 139  They offer research grants, testing services, and public policy initiatives both individual NEs and organizations (both in practice and academia).  and academia, and corporations, and offer products that help PD  - resources are done through workshops, coursework, conferences.  - membership is required for the individual and organizational levels.  partnerships with community stakeholders like academic institutions.  resources, perpetuating financial barriers for individual members.  51 Nevalainen M., Lunkka N., & Suhonen, M. 2018 Work-based learning in health care organisations experienced by nursing staff: A systematic review of qualitative studies.  Finland Systematic review of Qual-itative studies Aim was to summarize qualitative evidence about nurses’ work based (informal) learning in health care organizations.  - Culture of the organization instils a ‘culture of busyness’ and work is only a place for patient care, not learning.  - Need physical shared spaces for workplace learning as well as collaboration amongst colleagues to ensure opportunities are used.  - Lack of managerial support was largest obstacle for work-based learning due to favouritism of efficiency. 1. Workplace demands pull nurses away from work-based learning opportunities, and “routine performance of duties leads to a situation where nurses never stop to reflect and evaluate their own actions or the actions of the whole work community” (p. 27).  2. Barrier: Transactional leadership styles hinders nurses using learning opportunities that are relevant to them due to limited autonomy.   3. Barrier: physical infrastructure for workplace learning.   4. PD is not valued by managers.    1. Does not include formal learning because of their perceived “marginal effect on learning overall”.  2. Select studies had nursing home and LTC homes examined in same study, not related to my research question 


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