CME Needs Assessment: National Model - Nurses CME

(	Ninette Banday Abdulrazak Abyad Correspondence: Dr Abdulrazak Abyad Email: aabyad@cyberia.net.lb

Abstract This CME Needs Assessment paper was written to provide analysis on a particular regional country's <<the country>> proposed CME in Nursing program and can be used as a national model. In this new millennium most nations, both developed and developing are actively reviewing national health policies and strategies as well as health delivery systems. The over-riding imperative in all cases is to deliver quality nursing care in a cost efficient manner while addressing issues of access and equity. The provision of health services in <<the country>> is divided into federal, local and private sectors. The Health Authority, and the local government agency is responsible for the provision of integrated, comprehensive, and quality of health services for its population.

Introduction
The vision of <<the country>> is "To Provide World Class Healthcare." One of the first steps to achieve this vision is to start comprehensive educational programs to improve the skills of the primary health care team as Primary Health Care is essentially the first level of contact of the patient with the health care system. The suggested programs include the following:

• Interdisciplinary Primary Care Training Program. To assist medical centers in organizing their delivery of care around the of primary care principals.
• Primary Care Physician Education Initiative (PCPEI). The goals of the educational intervention are to better prepare current physicians to deliver care under this new paradigm.

Need Assessment Survey
In order to develop a comprehensive educational program for the health care team there is a need to carry extensive need assessment the first step in planning an educational activity. In an attempt to assess the needs for professional development of the medical, dental practitioners and nursing staff a survey was conducted by means of a Questionnaire (APPENDIX 1) by<<the country>>. The report takes into account a wide section of the various medical, dental and nursing staff. The wide range of topics that were covered in the survey is also well elaborated in the report included the following

Results of Survey

Demographic Data
465 questionnaires were included in the study out of 600 hundreds distributed. The exclusion criteria were that either the questionnaire was not returned or was incomplete. The response rate was 77 percent.

CME Topics for Nurses
The results for the CME topics for the nurses are presented in the Tables 30 and 31. Clinical
Practice Guide of Emergency Care, Professional Accountability & Legal Liability for Nurses, Medication Adherence in Children with Asthma/Diabetes, infection control and immunization were some of the topics that received high ratings for the need for CME activities.

Format of CME
The response rate for the monthly activity was the highest with Hands - workshops.

Recommendations
It is clear that looking at tables in the report that the respondents rated the importance of topics according to their level of knowledge. It is an important concept that revealed that the less knowledge they have about a topic was reflected by less score on rate of importance. Therefore in planning CME programs this should be taken into account.

Assessment Strategies
In the implementation of any CME activities assessment strategies is critical to judge the success of such a program. For example communication skills learning must be both formative and summative. The knowledge, skills, and attitudes to be assessed must be made explicit to both learners and teachers alike. Potential evaluators include local experts, course faculty, simulated and real patients, peers, and the learners themselves. Formative assessment should occur throughout the communication skills curriculum and is intended to shape and improve future behaviors. Assessment of communication skills must include direct observation of performance. Evaluation of setting a therapeutic environment, gathering data and providing information and closure must be included. Evaluation of advanced skills, including use of interpreters, providing bad news and promoting behavior change should be done as well. Criteria should match the novice level of the end of second year student, who should be able to identify the critical issues for effective communication and perform the skills under straightforward circumstances.

It will be as well a good idea to create a department of Family Medicine under the umbrella of <<the country>> that help coordinate the implementation of the different educational program, in addition to conducting a number of ongoing research and academic activities.

Conclusions
Quality CME can enhance the knowledge base and practice skills of the participating health care provider and is increasingly used as part of the credentialing and reappointment process. Continuing Medical Education is important not only as a requirement for practice, but as means for the profession to achieve one of its primary goals: QUALITY PATIENT CARE.

CME really is about changing behavior through education-about doing something different, doing it better." It is critical to look at CME and CPD in the mentality of 21st century. We attempted to clearly present: that the patient's concerns, values and outcomes must be the center of care; that partnering with an activated patient is essential; that self-awareness is essential in being an effective physician; that improving the process of care and health outcomes is the physician's responsibility and requires a systems approach.

Quality CME can enhance the knowledge base and practice skills of the participating health care provider and is increasingly used as part of the credentialing and reappointment process. Continuing Medical Education is important not only as a requirement for practice, but as means for the profession to achieve one of its primary goals: QUALITY PATIENT CARE.

Introduction to Project
In this new millennium most nations, both developed and developing are actively reviewing national health policies and strategies as well as health delivery systems. The over-riding imperative in all cases is to deliver quality health care in a cost efficient manner while addressing issues of access and equity.

By centering the focus of the program on the patient, rather than who provides the functions and services, we are best able to define our primary care program as the provision of integrated, accessible, cost-effective health care, wellness and preventative services through interdisciplinary teams. These teams are accountable for addressing the healthcare needs of their patients; developing a sustained partnership with their patients and practicing in the larger context of family and community.

Need Assessment
All health care disciplines share a common and primary commitment to serving the patient and working toward the ideal of health for all. While each discipline has its own focus, the scope of health care mandates that health professionals work collaboratively and with other related disciplines. Collaboration emanates from an understanding and appreciation of the roles and contributions that each discipline brings to the 'delivery of care experience'. Such professional socialization and ability to work together is the result of shared educational and practice experiences.

In order to develop a comprehensive educational program for physicians, dentists, nurses and the rest of the health care team there is a need to carry extensive need assessment. Needs assessment is the first step in planning an educational activity. Identification of needs provides the basis for writing activity objectives. Many sources may be used to establish needs. Physician needs may be determined through prior activity evaluations and/or surveys of individual needs. New advances in a clinical treatment may be identified as an area in which further education is needed. Needs assessment data may be drawn from surveys (on-site, email, Web site), focus groups, expert consensus, faculty perception, formal or informal requests from physicians, analyses of previous evaluations, epidemiological data, environmental scans including literature search/review, and quality assurance/improvement data (e.g., gaps between practice guidelines and practice performance, patient safety/institutional error data, and information from external entities such as licensing boards or certifying agencies, etc.).

It might seem self evident that the need to learn should underpin any educational system. Indeed, the literature suggests that, at least in relation to continuing professional development, learning is more likely to lead to change in practice when needs assessment has been conducted, the education is linked to practice, personal incentive drives the educational effort, and there is some reinforcement of the learning. On the other hand, basing learning in a profession entirely on the assessment of needs is a dangerous and limiting tactic. So a balance must be struck.

The definition of Need
As in most areas of education, for many years there has been intense debate about the definition, purpose, validity, and methods of learning needs assessment. It might be to help curriculum planning, diagnose individual problems, assess student learning, demonstrate accountability, improve practice and safety, or offer individual feedback and educational intervention. Published classifications include felt needs (what people say they need), expressed needs (expressed in action) normative needs (defined by experts), and comparative needs (group comparison). Other distinctions include individual versus organizational or group needs, clinical versus administrative needs, and subjective versus objectively measured needs. The defined purpose of the needs assessment should determine the methods used and the use made of the findings.

Exclusive reliance on formal needs assessment in educational planning could render education an instrumental and narrow process rather than a creative, professional one.

Methods of needs assessment
Although the literature generally reports only on the more formal methods of needs assessment, doctors use a wide range of informal ways of identifying learning needs as part of their ordinary practice. These should not be undervalued simply because they do not resemble research. Questionnaires and structured interviews seem to be the most commonly reported methods of needs assessment, but such methods are also used for evaluation, assessment, management, education, and now appraisal and revalidation.

Learning for needs
The main purpose of needs assessment must be to help educational planning, but this must not lead to too narrow a vision of learning. Learning in a profession is unlike any other kind of learning.

Thus, educational planning on the basis of identified needs faces real challenges in making learning appropriate to and integrated with professional style and practice. The first step is to recognize the need of learning that are a part of daily professional life in medicine and to formalize, highlight, and use these as the basis of future recorded needs assessment and subsequent planning and action, as well as integrating them with more formal methods of needs assessment to form a routine part of training, learning, and improving practice.

Methodology
Quality health care for patients is supported by maintenance and enhancement of clinical, management and personal skills. The knowledge and skills of practitioners require refreshment, and good professional attitudes need to be fostered through the process of continuing professional development. In an attempt to assess the needs for professional development of the medical, dental practitioners and nursing staff a survey was conducted by means of a Questionnaire (APPENDIX 1) by<<the country>>. This report takes into account a wide section of the various medical, dental and nursing staff. The purposes of the review, therefore were to:

• Determine the area of professional development
• Help the primary care physician, dentists, and nurses meet the challenge of changes in the structure and delivery of patient care.
• Encourage more reflection on practice & learning needs, including more forward planning; and
• Make the educational methods used in practice more effective

The topics that were covered in the survey included the following

CME Topics for Nurses
• Special Nursing Topics
• Medical Topics
Format of CME
Timing of the CME
Type of Activities
Self Study

Results
The results of the survey is presented in five parts, demographic data, physicians, dental, nurses CME and preferences. Statistical analysis was done using SPSS statistical package. The tables below represent a summary of the data collected.

CME Topics for Nurses
Ratings for the CME topics for the nurses was also rated in the same format as the physicians. The results are presented in the Tables 30 and 31.

Click here for Table 1: Special Nursing Topics

Table 2: Medical Topics


It is clear from the above table that the level of knowledge of the nursing staff in the medical topic is low which reflect the lack of any CME program for the nursing staff.

In order to upgrade the skills of nurses in primary health care there is a need to initiate the Primary Care Nursing Education Initiative PCNEI. The goals of the PCNEI are to :

• Provide Lifelong Learning opportunities for professional nurses regarding the latest developments, concepts, and research in advanced nursing practice and the profession of nursing.
• Increase awareness in the nursing community of current health care trends and practice issues.
• Collaborate with other health care professionals to provide educational opportunities for nurses and other members of the health care team.

It is important to show commitment from the authority to professional development support for nurses, for example:

• Professional continuing education opportunities available and supported;
• Resource support for advanced education in nursing, including RN-to-BSN completion programs and graduate degree programs;
• Preceptorships, organized orientation programs, re-tooling or refresher programs, residency programs, internships, or other educational programs available and encouraged;
• Incentive programs for registered nursing education for interested licensed practical nurses and non-nurse health care personnel;
• Long-term career support program targeted to specific populations of nurses, such as older individuals, home care or operating room nurses, or nurses from diverse ethnic backgrounds;
• Specialty certification and advanced credentials are encouraged, promoted, and recognized;
• APNs, nurse researchers, and nurse educators are employed and utilized in leadership roles to support clinical nursing practice; and
• Linkages are developed between health care institutions and baccalaureate/graduate schools of nursing to provide support for continuing education, collaborative research, and clinical educational affiliations.
• What resources are committed to the ongoing professional development of nurses, i.e. tuition, continuing education, and certification?
• How much is budgeted annually per staff nurse for attendance at professional development activities?
• Do you provide tuition reimbursement for nursing course work completed towards obtaining the next higher degree?

In this era of increasing health care workforce shortages, there is an ever expanding need for high-quality professional nursing care due largely to changes in the socio-demographics of the population and in the health care system itself. There is a critical need for PCNEI to fully utilize the knowledge and skills of professional nurses and to ensure their continuous professional development, and promote excellence in lifelong learning for all health care providers. In today's challenging healthcare environment, nurses committed to professional continuing education for nurses help maintain the standards of nursing practice and improve the health of the public.

Adult Learning Principles
In addition to being "champions," teachers need to employ principles of adult learning in their approach to teaching these topics. The knowledge base for any of these topics is changing every day with the information and technology explosion that has occurred in the last quarter-century. Genetics is a perfect example of a topic subject to rapid, ongoing revision based upon new research findings. Physicians must learn how to identify their own learning needs and address these needs effectively, in order to keep up with the ever-advancing knowledge base in most of these topic areas.

Self-Awareness
In addition to fostering an enthusiastic approach to lifelong learning, the instructional method must encourage physicians to reflect upon their own lives in relationship to the topic. The topic of geriatrics, for example, emphasizes many issues that every student will face, through the aging of parents and themselves. Substance abuse, end-of-life, and other topics often elicit strong emotions within students, as physicians remember past experiences or recognize ongoing struggles within their own lives. Teachers must create environments that are safe enough to foster trust and intimacy, and yet challenge physicians to reflect upon their own experience of life, as they develop a basic level of mastery in these special topic areas

Format of CME
Attempt was made to establish the most suitable timings and frequency of the CME activities.
The ratings adopted were :

1 being least appropriate, 5 most appropriate. The results are presented in the following tables and the need for a monthly activity was rated highest 3.95 with Hands- on Training.

Table 3: Timing of CME


Table 4: Type of Activities


Table 5: Self Study Methods


Interactive formats are not inherently beneficial nor always produce change. Some formats may be more conducive to specific changes in behavior and some to support. Group dynamics, facilitation, personal agendas, and internal and external influences contribute to the complexity of the format. In general, the focus was on choice of CME as opposed to other elements of the learning cycle. This approach has been documented previously and reflects the traditional approach to learning. It is well established that CME should follow the principles of androgogy - adult, self-directed learning. The term 'androgogy' has been coined to describe the learning culture appropriate to adult education . Whereas the term 'pedagogy' describes the teacher-centred approach to the education of children, androgogy 'recognises education to be a dynamic lifelong process' that 'is learner-orientated'. This is grounded in experiential learning - identifying and addressing needs and applying learning with continuing reflection.

CME & CPD for Nurses
The response of the nursing team to the survey was significant, it reveals the high lack of CME activities for nurses at the Emirate level. There is a great need to devise a comprehensive CME program to improve the skills of the nursing team within primary health care

Because the health care system is evolving and changing rapidly, continuous efforts to survey nurses and employers to identify content and skills needed for educational programs in nursing are essential. In Nursing learning is a life long process and continuing education is an integral part of professional development. While graduate and undergraduate education lead to formal academic degrees, continuing professional education consists of those learning activities intended to build upon the educational and experiential basis of nurses.

Changes in the social, political, economic and technological environments impact on the environment for health and health care and on professional practice. These changes provide challenges and opportunities for the nursing profession to develop and support effective CME program. The work environment for the practice of nursing has long been cited as one of the most demanding across all types of work settings. Nurses provide the vast majority of patient care in hospitals, nursing homes, ambulatory care sites, and other health care settings. The first objective of the professional practice environment for nurses is to put the patient first. Nurses and health care organizations must focus on patient safety and care quality and always ask the question, "What is best for our patients?"

In recent years a variety of factors have converged to challenge the work environments of contemporary nurses. Rapid advances in biomedical science, improved disease prevention and management, integration of new clinical care technologies, and shifts in care delivery to a broad array of clinical sites have contributed to the rapidly increasing need for well-educated, experienced nurses. Additionally, population demographics are changing as the public ages in growing numbers and becomes increasingly diverse in culture and language. Exacerbating the challenges to the work environment for nursing practice is the nationwide shortage of nurses and other allied health professionals.

Conclusion
CME really is about changing behavior through education-about doing something different, doing it better." The bottom line of CME in the past has been the activities we produced-how many, how much they cost, how many people came. In essence, CME was more activity-oriented than learner-oriented. "Not only do you have to focus on the learner," "you have to focus on the learner in the context in which they are learning, which is the healthcare environment where they practice medicine." The aim of the proposal is to 'to provide leadership in the delivery of high quality education, for the primary care team, in the context of a caring and vibrant academic environment'

It is critical to look at CME and CPD in the mentality of 21st century. We attempted to clearly present: that the patient's concerns, values and outcomes must be the center of care; that partnering with an activated patient is essential; that self-awareness is essential in being an effective physician; that improving the process of care and health outcomes is the physician's responsibility and requires a systems approach.

Quality CME can enhance the knowledge base and practice skills of the participating health care provider and is increasingly used as part of the credentialing and reappointment process. Continuing Medical Education is important not only as a requirement for practice, but as means for the profession to achieve one of its primary goals: QUALITY PATIENT CARE. To our patients CME requirements are a commitment made by the medical and dental practitioner to keep our knowledge and skills current.

APPENDIX
SURVEY: CME TOPICS FOR NURSES

Please rate each of the topics below

(a) In order of importance for you to have CME on the topic (1 = least important to 5 = most important)
(b) By rating your own current level of knowledge of the topic. (1 = basic to 5 = highly skilled)
(c) Recommend CME activity on level of priority. ( 1=least to 5 = highest priority )




Any other skills or topic you feel are important for your academic development:

Personal Information (optional)

Name ___________________________
Degree ___________________________
E-mail ___________________________
Work place _______________________

Are you willing to help in the teaching process of the CME?