illuminating continuing professional education: unpacking the black box

International Journal of Nursing Studies 42 (2005) 97–106

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doi:10.1016/j.ijn

Illuminating continuing professional education: unpackingthe black box

Lorraine Ellis*, Mike Nolan

School of Nursing and Midwifery, University of Sheffield, Bartolome House, Winter Street, Sheffield, S3 7ND, UK

Received 10 November 2003; received in revised form 22 April 2004; accepted 11 May 2004

Abstract

This paper reports on a longitudinal study of continuing professional education (CPE) in nursing using a case study

approach operationalised within an illuminative evaluation model. Using a short focussed programme as an

instrumental case study, the project gathered data from three major groups of stakeholders over an 18 month period in

order to explore the context within which CPE operates, and to highlight those factors which appear to influence the

outcomes of CPE over time. Data were collected using documentary analysis and in-depth semi-structured interviews

with educators, students on the programme (the ENB 941), and their managers. The latter two groups were interviewed

at four points in time (prior to the course, immediately post course, 6 and 12 months post course). Data analysis

revealed that a complex set of factors interact to influence the outcomes of CPE, including the nature of the selection

process, students’ expectations of the programme, the nature of the educational experience, and the receptivity of the

practice environment to change. This paper identifies those factors that shape the outcomes of CPE and considers their

implications for policy and practice.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Continuing professional education; Illuminative evaluation; Longitudinal case study; Practice change

1. Introduction

The last 20 years have seen significant changes to the

education of nurses at both pre- and post-registration

levels. The impetus for this change has come from

different and varied sources both within and outside the

nursing profession.

Under successive Governments the National Health

Service (NHS) in the UK has been the subject of

continuous review and modernisation that has necessi-

tated the examination and revisioning of the provision

of education for nurses.

The modernisation of the NHS has its origins in a

programme of reforms legislated for in the NHS and the

ing author.

ess: [email protected] (L. Ellis).

e front matter r 2004 Elsevier Ltd. All rights reserve

urstu.2004.05.006

Community Care Act in 1990, arguably one of the most

radical and far reaching legislative changes of its time

(Fields, 1991; Sunter, 1993). This act emerged, in part, in

response to advances in research and technology,

demographic changes such as an ageing population

(WHO, 1979) and the concomitant changing health care

needs of the United Kingdom. Hard on the heels of the

NHS Act followed a series of NHS policies and reforms

spanning the next decade (DoH, 1994, 1997, 1998a, b,

1999, 2001). The most recent of these is the NHS Plan

that is designed to give the people of Britain a health

service fit for the 21st century (DoH, 2002a, b).

A major reconfiguration of the NHS workforce has

followed as a consequence of these reforms resulting in a

reduction in the working hours of doctors (DoH, 1991),

the introduction of new roles such as the nurse

consultant, and the inception of the modern matron

role (DHSS, 1986; DoH, 1989, 1995; COD, 2002).

d.

ARTICLE IN PRESSL. Ellis, M. Nolan / International Journal of Nursing Studies 42 (2005) 97–10698

Responding to the changing patterns of service

delivery resulting from the modernisation of the NHS

has necessitated major revisions to nurse education at

both pre- and post-qualification levels (Project 2000

UKCC, 1986; PREP UKCC, 1990, 1995; Working

Paper 10 DoH, 1989, 2000, 2001, 2002b; HEFCE,

2003; DfES, 2003). Collectively, these initiatives actively

promote an ethos of lifelong learning, resulting in a

major orientation on continuing professional education

(CPE) or continuing professional development.

It has long been argued that CPE potentially impacts

positively on nursing care, but that several complex

factors operate in determining its success (Wake, 1987;

Nolan et al., 2000; Ellis, 2001). As will become evident in

the study reported in this paper, the success of CPE is

context and time dependent, and pivotal to an under-

standing of success is the need to take account of the

complexities that impact on the practice environment.

Using an ‘illuminative case study’, this paper explores

the impact of CPE over time and provides potential

explanations for what determines whether positive

change results. The results are of interest to a range of

stakeholders, including: education providers; purchasers

of CPE, whether the candidates themselves or their

sponsor who is normally their manager; and education

researchers, as well as policy makers and professional

bodies. The paper begins with an overview of the

literature that informed the study before presenting the

results from a temporal perspective.

2. Literature review

The study began with a comprehensive review of the

literature covering the 50 year period from 1945 to 1996.

The following databases were interrogated: CINAHL;

ENB (English National Board); Intended Nursing

Index; Educational Resources Information Centre;

RCN Nurse ROM; Dissertation Abstracts Interna-

tional, and the following key words were used: CPE;

post-registration nurse education; continuing education;

nurse education; benefits of continuing education; high-

er education; education and training. Electronic search-

ing was complemented by a hand search using an

incremental approach (Burnard, 1993). Those interested

in the detailed results of the complete review process are

referred to Ellis (2001). Here we provide a broad

overview that synthesises the key themes to emerge.

The intention of the review was to identify areas in

need of further investigation and to synthesise the

existing literature in order to distil the features and

characteristics of a well-functioning system of CPE. The

review indicated that most studies of CPE have focussed

on the outcomes of education at a discrete point in time,

with far less attention being given to the processes

involved. Furthermore, it emerged that there have been

very few longitudinal studies that have mapped experi-

ences of CPE before, during and after the delivery of a

programme. Moreover, while several benefits of CPE

have been identified, the extent to which these are

sustainable over time has rarely been considered.

Interestingly, the potentially negative effects of CPE

have not been considered in most studies.

A synthesis of the available literature suggested that if

CPE is to be optimally effective then it is best delivered

as part of a systematic and carefully planned approach

that acknowledges the needs and aspirations of several

stakeholders (staff, employing organisations, patients/

clients). The CPE programmes should be responsive,

accessible and based on a partnership between those

providing and those receiving education. The literature

also highlighted the need to create a supportive and

enabling practice environment if the benefits of CPE are

to be fully realised. In such circumstances, the literature

suggests that a range of professional, personal, person-

nel and practice-related benefits can be realised. The

interaction of these factors is summarised in Fig. 1.

As a result of the above review, a number of research

questions were identified and the study aimed to address

these in a longitudinal fashion. The main questions, with

an indication of how they relate to the results of the

study, are as follows:

* What are the perceptions, expectations and motiva-

tions of students and managers before undertaking a

programme of CPE? (See results: Going in).* How do the above factors influence the way students’

experience the programme? (See results: Coming

out).* What is the nature of the educational experience itself

and how does this impact on subsequent outcomes?

(See results: Coming out).* What are the students’ and managers’ perceptions of

the outcomes of the course immediately following the

programme? (See results: Coming out).* In what ways do the perceived outcomes change over

time? (See results: Reaping the benefits/carrying it

on).* What factors influence the perceptions of programme

outcomes over time? (See results: Reaping the

benefits/carrying it on).* What factors influence whether practitioners are able

to initiate change following the programme? (See

results: Reaping the benefits/carrying it on).

3. Research strategy and methods

Few studies evaluating CPE have fully acknowledged

the complex multidimensional nature of the educational

process and there has been relatively little focus on how

the curriculum is interpreted, applied and received.

ARTICLE IN PRESS

Pre-Course Assessment Potential Benefits

Clear organisational goals/objectives Increased knowledge known to all parties Attitudinal change

Professional Career development Exchange of ideas

Systems that acknowledge and reconcile Potential differences in expectations of CPE

Systems to identify need CPE that is Develop critical thinking

Responsive Personal/ Increased self confidence Recognition of impact on patients/clients Accessible Professional Enhanced interdisciplinary

Partnership-based working Supportive

Systems for determining learning needs ideally involving nominees, managers, educators

Staff retention enhancedPersonnel Staff recruitment enhanced

Systems which monitor whether needs have Motivation been met and the impact of CPE Stress/burnout

Planned career development Practice Improvements in care

Fig. 1. Diagrammatic synthesis of the literature—an idealised system of CPE need and its potential benefits (source: Ellis, 2001).

L. Ellis, M. Nolan / International Journal of Nursing Studies 42 (2005) 97–106 99

Indeed, educational evaluation generally has tended to

suffer from several limitations, including:

* a failure to acknowledge that different groups may

not value the same outcomes or objectives, and that

definitions of success are likely to vary;* an over-reliance on a positivist view of the world

based on an objective and value-free reality;* a consequent tendency to strip programmes of their

context and thereby fail to provide important

explanations as to how and why programmes work

or not. (Guba and Lincoln, 1989).

In an effort to overcome such limitations, the present

study applied a case study approach as a ‘disciplined

qualitative mode of inquiry to the study of educational

programmes’ (Stake, 1995, p. xii). As the study wished

to explore students’ and managers’ experiences of

education within a particular context, but also wanted

to be able to draw a wider set of inferences, it was

decided that an instrumental case study was the most

appropriate approach, and this was operationalised

using a modified form of ‘illuminative evaluation’

(Parlett and Hamilton, 1987) in the form of an

‘illuminative case study’ (see Ellis, 2001 for a detailed

account).

The ‘case’ in question was a short focussed ENB

course (ENB, 941), which was intended to equip

participants with the knowledge and skills required to

meet the needs of older people. In operationalising an

illuminative case study, the main forms of data

collection used were documentary analysis of the course

curriculum and supporting literature, and interviews

with educators delivering the programme, students

undertaking the programme, and their managers. This

paper focusses on the interview data collected from

students and their managers at four points in time: prior

to the course commencing; immediately post course; and

6 and 12 months post course.

All of the interviews were tape-recorded, transcribed

verbatim and initial analysis undertaken following each

interview. Themes emerging from this analysis then

informed subsequent interviews using a constant com-

parative approach (Charmaz, 2000). Data were collected

from 15 students and 21 managers over an 18-month

period, resulting in 121 in-depth interviews providing

detailed insights into their perceptions and experiences

at several points in time.

4. Results

While case studies do not produce results that are

generalisable per se, it is widely acknowledged that with

careful reporting and attention to context, the insights

provided can be ‘related’ (Bassey, 1984), ‘transferred’

(Guba and Lincoln, 1989) or ‘recontextualised’ (Morse,

1994) to different settings. Consistent with the original

tenets of an illuminative model of evaluation the

primary aim of the study was to identify ‘recurring

concomitants’ and ‘general principles’ that could be used

to disentangle complexities and provide clues as to

important relationships that shape the processes and

outcomes of educational programmes (Parlett and

Hamilton, 1987).


Given that the study wished to provide a longitudinal

understanding, the results are presented here in a

temporal fashion, which reflect the interviewees’ unfold-

ing experiences over time. Four phases were identified

corresponding to the points in time that the interviews

were conducted. These were named:

‘Going in’—pre course expectations and experiences

‘Coming out’—immediate post-course perceptions

‘Reaping the benefits’—perceptions and expectations

6 months post course

‘Carrying it on’—perceptions and experiences 12

months post course.

Initially, these four phases will be considered sepa-

rately but subsequently a synthesis of the results is

provided which distils the wide-ranging factors that

impact on CPE and act either to limit or enhance its

potential benefits.

4.1. ‘Going in’

Analysis of the interview data from the students and

managers prior to the course identified a number of

tensions and inconsistencies in their perceptions and

expectations which presented a quite different picture to

that portrayed in the literature (see Fig. 1).

What was particularly striking and immediately

apparent from these initial data was the haphazard

and ad hoc manner in which selection for the

programme was made. Most students (n ¼ 14) had been

selected randomly, with their manager informing them

of the availability of a place on the course and asking if

they were interested. Some happened to be at the top of

a ‘waiting list’ (n ¼ 2), whereas for others the vacancy

fortunately fell at the time of their annual staff appraisal

(n ¼ 3). Another candidate learned of her nomination

through a colleague who had declined the offer of a

place on the same course. The manager had offered the

place to her colleague first, simply passing it on to the

interviewee when she was unable to take it. None of the

nominees had been required to specify their reasons for

wishing to attend the ENB 941, to state what they hoped

to gain, or to indicate how they might use the ENB 941

post course. For example:

I wasn’t asked anythingyonlyydid I fancy doing

the 941.

There was no real discussion between the student and

their manager pre course, and even when discussions did

take place (n ¼ 2) these tended to focus on the

practicalities of the course, rather than the nominees’

expectations of the programme and how they might seek

to influence practice post course.

4.2. Students’ motivations, expectations and concerns

The interviews revealed that few of the students had

any desire to attend the ENB 941 per se, but with the

limited availability of CPE places saw it as an

opportunity to take ‘what was going’. Indeed, one

candidate was even unsure of which course she was

attending, asking the researcher ‘yit is care of the

elderlyyisn’t it?’. Even those candidates who could give

explicit reasons for attendance rarely related these

directly to working with older people; it was simply

their intention to ‘keep ahead of the game’ by being one

step ahead of their colleagues. Other generic motivations

for pursuing the course related to getting time out from

a hectic work environment in order to ‘recharge my

batteries’. Despite the lack of clearly articulated goals,

all the interviewees were pleased to accept the offer of a

place on the course, as the perceived lack of CPE

opportunities meant that staff seized upon any offer

made. However, notwithstanding their initial enthu-

siasm, most interviewees also expressed a number of

concerns.

All but one of the candidates (a recently qualified

Project 2000 nurse) were worried about the academic

component of the course, and questioned their ability to

successfully complete the programme (‘can I hack it’),

especially in the face of competing work and home

demands (‘juggling too many balls’).

I’m frightened that I won’t be able to cope with it. I

don’t want to be a failure; I want to be able to do it.

When I was in [nursing] school we did a composition,

now it’s an assignment, portfolio, I’ve never heard of

modules either.

Perhaps, understandably, such concerns were more

apparent in those with young children (n ¼ 3). However,

managers were largely unaware of such concerns, which

exacerbated the anxiety and uncertainty amongst

students, with such uncertainties being further heigh-

tened by their limited understanding of what their

manager expected them to gain from the course.

In summary, the pre-course interviews with nominees

painted a picture, which in many ways was the antithesis

of the carefully planned approach advocated in the

literature. The selection process was mainly random,

with minimal discussion about the course or students’

expectations and motivations. Informants provided a

number of reasons for accepting the offer of a place,

although for most the shortage of CPE opportunities

was the key factor (n ¼ 9). Other motivations were also

mostly generic in nature rather than specific to the care

of older people. However, a small number of inter-

viewees (n ¼ 5) were enthusiastic about the course and

genuinely interested in increasing their knowledge about

older people. These individuals had a better, but still

ARTICLE IN PRESSL. Ellis, M. Nolan / International Journal of Nursing Studies 42 (2005) 97–106 101

largely implicit, idea as to what they hoped to gain from

their studies in relation to their practice.

Regardless of their disposition towards the course,

their concerns about the academic component, or the

practicalities of balancing the competing demands of

practice, the course and home life, none of the

candidates declined the offer of a place. Furthermore,

in most instances nominees considered that managers

remained unaware of their expectations of, or concerns

about, the course. Overwhelmingly, therefore, pre-

course data suggested that nominees were by and large

unprepared for the course of study they were about to

embark upon. Attention is now turned to the views of

their nominating managers.

4.3. Managers’ views

In many respects, managers’ views were in marked

contrast to those of the students, particularly with

respect to the selection process. Managers identified a

range of selection criteria that they said they applied,

such as the motivation and commitment of the student,

and their seniority and grade. Paradoxically, managers

admitted to not having used these criteria to select the

students in the study, rather, as they stated, they tended

to make judgements about whether or not staff wished

to access CPE for the ‘right reasons’. Managers were

particularly keen to avoid ‘title collectors’ or ‘course

hoppers’:

There are always staff who go round collecting

titlesyare they going on it [ENB 941] because they

want to go on a course, or is it just something else to

put on their CV.

Whilst the managers placed great emphasis on

selecting the ‘right candidate’, they were often unable

to specify the criteria they used to judge whether or not a

candidate was ‘right’. Even where there were more

explicit expectations and a purposeful and planned

process of selection was adopted, decisions were still

largely based on generic criteria, such as ‘being next in

line’, rather than those specific to the care of older

people. Therefore, whilst it might be said that efforts

were made to try and ensure a degree of equity in who

attended courses, the selection process was unfocussed.

Generally, there was no assessment of the candidates’

educational needs and no discussion about the respective

views of staff and managers.

Despite the rather ad hoc selection process most

managers claimed to have clear expectations of their

staff post course, although they had not communicated

these expectations to any of the students. It also

transpired that managers had very little knowledge of

the aims and content of the current ENB 941

programme, despite many of them having completed

the course previously. To compound difficulties, most of

those interviewed were largely unaware of staffs’

concerns, especially relating to the academic elements

of the course. In the longer term, very few managers

(n ¼ 2) had any strategy for evaluating the effectiveness

of the education post course.

I must confess I haven’t done this with anyone

[evaluated the ENB 941], but I guess what you could

do is justywell you’d have to discuss it with them,

ask them what they got out of it really. Although I

don’t know how valuable that is because sometimes

they’ll say it was brilliant when really they think its

not. I mean I’ve done that before.

Overall the pre-course data suggest that few, if any, of

the canons of a ‘good’ selection process, as identified in

the literature, were applied. As will become apparent

later, this served to limit the effectiveness of the

educational input.

4.4. ‘Coming out’: perceptions immediately post course

Students’ perceptions and experiences of the course

itself varied. Post course some were enthusiastic and saw

themselves as having benefited, believing that the course

was relevant to their practice (n ¼ 6). Conversely, others

suggested that the course had been of only limited

relevance (n ¼ 5). Although several factors contributed

to students’ evaluation of the educational experience, the

perceived relevance of the course content and the

manner in which it was delivered were uppermost.

Sessions that actively encouraged student participation

and which forged links to practice were the most valued.

Much also hinged on whether or not the person delivering

a particular session was seen to have ‘street cred’.

It was nice to be taught by somebody who was

obviously a skilled practitioner. She wasn’t some-

body removed from practiceyit was nice to identify

with somebody who I had respect for in that position.

Many aspects of the course itself were thought of as

being too generic and as having little relevance to elderly

people. Moreover, several of those interviewed consid-

ered that too little attention had been given to their

concerns about their academic ability. Notwithstanding

the limitations of the course itself, students identified a

number of both positive and negative outcomes.

Those students who had been enthusiastic about the

ENB 941 pre course identified the most benefits and

considered that they had increased their knowledge in

relation to older people. They had begun to question

‘taken-for-granted’ practices, and now had a better

appreciation of research:

For a long time, if I looked at a piece of research I

would have said ‘yes, all these clever people in ivory


towers have put this together therefore it must be

right, therefore I must do it!’. What I hadn’t done

was to say ‘is this research appropriate to my sphere

and is it a valid piece of research?

Certainly, the course had increased the confidence of

several students, who now felt better able to assert their

views:

I’m hoping they’re going to realise that I’m going to

be a bit more pushy—assertive is the word I should

be using, professionally assertive—buzz word. Edu-

cation is a wonderful thing.

At this early stage few of the students had introduced

changes to practice but a number (n ¼ 5) planned to do

so. However, even at this juncture such individuals

questioned the support they would get from their

managers if they attempted to introduce change.

The more negative consequences of the course were

usually voiced by those informants with family respon-

sibilities and/or who worked shifts, who described

tensions between the competing demands of home,

work and study. This was especially so for informants

who had struggled with the academic demands of the

programme. Certainly, pressures external to the course

appeared to exacerbate anxieties about academic work,

particularly amongst the mature students who had

doubted their academic abilities at the outset. None-

theless, despite having struggled with the course, such

individuals were often those who thought that they had

benefited the most and viewed their overall experience

positively.

The data from the managers suggested that many

were largely unaware of the students’ experiences on the

course, of their feelings about it, and of their plans to

introduce change. There was little evidence of any

sustained and systematic attempt by managers to

evaluate the outcomes of the programme, for example,

one said: ‘I was hoping to catch her (nominee) this

morning when I realised you were coming’. Despite this

most managers considered that their staff had benefited

from the experience. However, some did pay more

attention and appeared to take a genuine interest in both

staffs’ experiences of the course and its impact on their

practice:

She’s considering issues that we’ve tried to hide in the

past—taboo subjects like sexuality. We discussed

whether a particular patient’s sexuality was abnormal

and thought about our prejudices.

On the whole, however, the relative lack of attention

to staffs’ perceptions post course created frustration

amongst some of the staff interviewed, particularly those

who thought that they had benefited and were keen to

share their new knowledge with others.

4.5. ‘Reaping the benefits’: perceptions 6 months later

At a point 6 months post course, a number of benefits

of the ENB 941 were emerging, as were a range of

barriers to change. Informants often described a more

holistic approach to their care, and detailed their

attempts both to empower older people and to challenge

prevailing stereotypes amongst some of their colleagues:

I must keep fighting for the needs of elderly people

and not have them brushed aside because they have a

certain birth date. I still find it difficult to swallow

that one day you are a worthy person and you get

treatment, and the next you are over the hill. So I try

to stick up for people who are in that age group

because they too have valid needs.

However, as well as gently confronting colleagues

with their potentially ageist attitudes, a number of staff

(n ¼ 5) were also keen to provide opportunities for peers

to benefit from what they had learned on the programme

by sharing information and raising awareness. For a

minority of those interviewed (n ¼ 3), attendance on the

ENB 941 had revitalised their enthusiasm for their work

with older people:

If anything its [ENB 941] made me get more

enjoyment out of working. Perhaps I value my job

more that I did—I’m definitely happier. I heard

myself saying to a student ‘well it is a wonderful job

because no two days are the same’.

The course was brilliant but its all the after effects—

its like when you’ve got your driving test and you

learn just how to pass the test and then you go on to

learn to drive. And I think that’s what this [ENB 941]

has done. ‘ybut it is only the start. I feel that this

has been the bottom building block—I’m ready to go

out and do more with the elderly.

Despite such positive effects several interviewees

(n ¼ 10), including a number who had identified a range

of benefits, identified several barriers to change that

limited the impact of their efforts. Foremost amongst

these was the perceived continued indifference of their

managers, with the majority of staff having had no

further discussions (n ¼ 11) since the last interview 6

months earlier. Staff consequently felt thwarted or

discouraged from taking their ideas further. Conversely,

in the small number of cases where staff received

positive and proactive managerial support, enthusiasm

remained high. Such individuals were those who had

been most enthusiastic both pre and post course.

When managers were asked about their efforts to

monitor staff progress, few could provide specific

examples but most were nevertheless still of the opinion

that staff had benefited. There were, however, excep-

tions, and some of the managers not only thought that


staff had benefited, but were also obviously following

their progress:

The one thing I like about her [since the ENB 941] is

the way that she implements ideas. Before, if she had

a new idea there was no structured approach to

implement it. You have to involve people and she has

realised that if you want to implement a new idea

you’ve first got to sell it to other people.

It was within these more supportive and enabling

practice environments that the positive outcomes of

CPE were maximised.

4.6. ‘Carrying it on’: perceptions at 12 months post

course

By 12 months post-course, interviewees had less to say

and only three of the 11 staff who were interviewed

talked in terms of positive outcomes, although interest-

ingly one of these had not considered herself to have

benefited until this point in time. The positive outcomes

cited remained similar to those identified at 6 months

post course and related to creating a more enabling and

individualised environment of care for older people,

which challenged ageist attitudes. Increased self-con-

fidence was still apparent for certain individuals, as was

a desire to take their education further.

However, by far the most prevalent theme at this

point was the dissatisfaction voiced about the apparent

indifference of managers, both with regard to their lack

of interest in their staffs’ efforts to introduce change

and, with hindsight, to the ad hoc and fragmented

nature of the whole education experience:

NOBODY discusses anything before hand [before

the ENB 941] and nobody discusses it after and says

‘what have you learnt and can you bring anything

back!’

If my manager had said exactly what the course

entailed and covered I’d have been against it, that it

wasn’t for me. But she didn’t really know anything

about the course, Just that it was care of the elderly.

The nature of the clinical environment (or practice

milieu, Ellis, 2001) to which staff returned following

completion of their course was now the main source of

discontent, with the emphasis firmly placed on the lack

of managerial support for initiating and sustaining

change.

One of the most striking and significant features of the

data was that those staff who gained the greatest benefit

from the course were those who were enthusiastic pre

course. This was in contrast to those who perceived the

course to have been of limited relevance and who were

largely indifferent to the programme pre course (n ¼ 9).

This suggests an association between the disposition of

individuals towards a course and its subsequent out-

comes. Importantly, those individuals who appeared to

benefit the most worked in practice areas that were

receptive and enabling, and where staff were empowered

to act and encouraged by their manager to introduce

changes resulting from the course. This highlighted the

importance of the receptivity of the ‘practice milieu’ as

one of the most significant factors determining whether

the benefits of CPE are realised (Ellis, 2001, 2003). We

consider this more fully in the discussion.

Disappointingly, barriers to change were highlighted

throughout the series of interviews and the frequency

with which they were mentioned increased over time,

reflecting the ongoing frustration of staff and the

perceived inadequacies of the practice milieu. Indeed,

irrespective of whether staff felt they had benefited from

the course, all were agreed that managerial support (or

the lack of it) was a key factor determining whether

change could be introduced. A lack of support created

frustration in some staff and contributed to a decrease in

motivation, which reduced staffs’ enthusiasm for further

education. Therefore, despite some individuals being

enthused by the course and returning to their clinical

area keen to use their knowledge to improve practice,

their motivation was soon dampened by the perceived

indifference of their managers.

4.7. Illuminating CPE

As noted earlier, case studies do not permit general-

isations per se but rather provide detailed insights and

understandings, which can be ‘related to’ (Bassey, 1984)

or ‘recontextualised’ (Morse, 1994) to other settings. In

respect of an ‘illuminative’ evaluation, the aim is to shed

light upon those ‘recurring concomitants’ (Parlett and

Hamilton, 1987) that help to disentangle the complex

array of factors that operate in the multi-faceted

environment of the social world.

A synthesis of the results from the present study

suggests that several factors interact over time to

influence the potential outcomes of CPE, beginning

before the course commences and continuing for months

or even years afterwards. We would see these as being:

* the way in which staff are selected for CPE;* staffs’ disposition towards the course, and their

motivations for undertaking CPE;* the quality of the educational experience itself;* the nature of the ‘practice milieu’ to which staff

return.

We would suggest that each of these factors can be

conceptualised as comprising a continuum, with ‘best

practice’ at one end and ‘poor practice’ at the other. This

is represented diagrammatically in Fig. 2.

In terms of the criteria suggested in Fig. 2, our data

suggest that elements of ‘best practice’ were in the


minority and that by and large staffs’ experience was

more likely to reflect the right-hand side of the

continuum.

If we consider the temporal dimensions of the study

from ‘going in’ (pre course expectations) to ‘coming

out’, ‘reaping the benefits’ and ‘carrying it on’, it is

possible to identify a number of broad trajectories that

capture the subtle range of factors that influence staffs’

CPE journey. Fig. 3 represents an attempt to capture

these, with reference to factors identified in Fig. 2.

Best practice

NATURE OFSELECTION PROCESS

Systematic, planned. Full discussion of motivations, concerand expectations of all parties. Equitaand fair.

STAFFS’ DISPOSITION TOWARDS THE PROGRAMME

Fully aware of content, aims and demands of programme, interested in programme for its own sake.

QUALITY OF EDUCATIONAL EXPERIENCE

Highly relevant, well coordinated, participative, high ‘street cred’.

NATURE OF PRACTICE MILIEU

Highly facilitative. Openly and actively supportive, autonomy and innovation encouraged.

Fig. 2. Features of best and poor practi

GOING IN

Nature of selection process Systematic/plannedInitial discussion

Disposition towards programme

I’m really interested(Minority)

COMING OUT

Perception of educational experience

Relevant, stimulating, challenging

Enthused, feel good aboutself, opened eyes, question old ways

Empowered

Empowered

Disempowered

REAPING THE BENEFITS Enthused, feel good aboutself, challenge stereotypes Holistic assessment

Reflection

ReflectionCARRYING IT ON

Real and enduring change

Practice Milieu Fully supportive Facilitative

Fig. 3. Recurring concomitants: a longitu

Starting at the top left-hand corner of Fig. 3, the study

suggests that only a minority of staff began their journey

‘really interested’ in the programme, with the majority

simply ‘taking what’s going’. Conversely, virtually all of

the staff had concerns about the academic demands of

the course (and their ability to meet these) and/or the

competing demands of home, work and study. However,

such concerns were not recognised by managers, nor

addressed during the course. Despite this, most students

managed to complete the course usually in spite of,

Poor practice

ns ble

Totally ad hoc, random, no apparent planning or discussion. Discriminatory/biased.

Nature of programme is irrelevant, simply a matter of taking what’s going. No awareness of the content, aims and demands of the programme.

Little/no relevance, fragmented, largelydidactic, low ‘street cred’.

Hostile, subversive, barriers created, status quo protected.

ce in relation to CPE (Ellis, 2003).

hoc/randomNo planning or discussion

Take what’s going’ (Majority)

‘Can I hack it?’Concerns, apprehensions,competing demands (Most/all)

Little relevance or challenge

Disenchanted with programme

Reflection

Reflection

Disenfranchised

Less likely to challenge stereotypes etc

Little likelihood of change

Little real change No real change

Largely indifferent Openly hostile

Risk of becoming

Ad

dinal model (based on Ellis, 2001).


rather than because of, the support they received from

their managers. Those who completed the course and

who had started off ‘really interested’ were likely to

return to the clinical environment motivated to intro-

duce change. If they subsequently experienced a facil-

itative (or at least a largely facilitative) practice milieu

they were empowered to challenge stereotypes and

introduce holistic assessment, providing a catalyst for

real and enduring change. The on-going support of their

manager and colleagues was a key factor here. Of

particular importance was a manager who shared an

interest in what the staff member had achieved, and

encouraged and supported them to introduce new ideas.

However, those who returned enthused but were met

with a less facilitative practice milieu, where there was

little interest or even some hostility, were often

disempowered, and subsequently became disenfran-

chised, with their potential for change significantly

diminished. They were subsequently likely to become

disenchanted.

Whilst in a study of this nature we did not set out to

‘measure’ a facilitative environment in which staff felt

empowered to act, our data clearly highlight the need to

have a supportive managerial ethos if change is to ensue.

The study also highlights the additional understandings

to be gained from adopting a longitudinal approach.

Many of those interviewed started with limited

expectations of the course itself and consequently found

the programme, at least upon initial reflection, to be of

little relevance. They subsequently became disenchanted

with the programme, and sometimes with education

more generally. As most returned to a largely indifferent

practice milieu, or at least to one in which work

demands and limited resources were to the fore, there

was little to counteract their feelings of disenchantment.

What is interesting, however, is that during the inter-

views at 6 and 12 months, a small number of nominees

had reflected upon their initial disenchantment and

become more enthused about the effects of the

programme upon their practice. This demonstrates the

value of a longitudinal study but leaves unanswered

questions about whether this reflection was part of a

natural process of maturation, or whether in fact it was

precipitated by the research process itself.

In a study of this nature, it is important not to extend

potential inferences too far beyond the data or to make

causal or definitive statements. It should also be

acknowledged that our data were perceptual, that is,

they were based on the interpretations of those

interviewed. No observational or other data were

collected. However, in terms of an illuminative evalua-

tion it is reasonable to suggest that the significant

features identified in Fig. 2 (selection process, disposi-

tion towards programme, quality of educational experi-

ence and practice milieu), and the recurring

concomitants illustrated in Fig. 3, are supported by the

data and account for many of the ‘critical processes’

which exert ‘significant influences’ on the experiences

and outcomes of CPE, at least insofar as this study is

concerned.

5. Conclusion

The study provides a detailed account of the impact of

CPE and the critical processes that contribute to its

success using a longitudinal ‘illuminative case study’.

This illuminative approach served to unpack the

complexities of CPE highlighting a number of significant

features and recurring concomitants that help to high-

light the factors that influence whether CPE is likely to

be successful or otherwise. Unpacking and illuminating

this particular black box presents a fuller and more

complete account which should help to shape future

decisions concerning the provision and purchase of

nurse education. A more informed process is central in

today’s climate of evidence-based care (Dawes et al.,

2003) where quality assurance (QAA, 2000) is a

recurring theme, whether in the form of benchmarks

for NHS funded education and training (DoH, 2002b)

or debates about improving standards in post-graduate

research degree programmes (HEFCE, 2003). Both the

NHS and the higher-education sectors are united in the

need for enhanced provision, and the present study can

help to provide insights as to where changes are

required.

One of the key findings to emerge from this study is

that whilst a multitude of factors influence CPE, the

primary determinant in whether continuing education is

successful, at least within nursing, is the practice milieu.

Clearly, there is a need to look beyond the outcomes

achieved at the end of a programme of study and to

create both structures and mechanisms that not only

support innovation and change but also encourage

continued reflection and dialogue. Certainly, closer links

between the respective parties will be essential not only

within the context of the NHS, but also to ensure that

new frameworks for Higher Education become more

than rhetoric. Collaboration between the key players is

crucial if the link between quality education and quality

care is to be realised and the benefits of continuing

education for nurses maximised.

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