Nurses’ Awareness and Participation in Mandatory Continuing Professional Development in the Philippines: A Pilot Survey

Introduction: Mandatory Continuing Professional Development (CPD) in the Philippines is relatively new. The purpose of the study was to determine nurses’ awareness and participation in CPD in the Philippines. Methods: This descriptive survey was conducted among nurses (n=30) in a private hospital in Iloilo City. A researcher-made survey tool was used to gather data. Data were analyzed using descriptive statistics and Mann-Whitney U to test for differences between variables. Results: Results indicated that were nurses were generally aware of the CPD law and its implementing rules and regulations (IRR). However, while nurses understood the concept of CPD and the renewal requirements of the CPD Act, more than half were not aware of learning activities under Self-Directed Learning and that nurses can earn CPD credit units through online CPD programs. Almost half were unaware that excess CPD cannot be carried over to the next three-year period, and more than one-third were unaware that only completed post baccalaureate degree programs can be used to earn CPD credit units. There were no significant differences in the awareness of nurses when grouped according to sex, age, civil status, position, salary, and length of work experience. Seminars and workshops were the most common CPD activities participated by nurses in the last 12 months. Conclusion: Addressing the common information gaps regarding the CPD law identified in this study may assist in increasing nurses’ support in the implementation of the mandatory CPD among nurses.


INTRODUCTION
Republic Act No. 10912 or the Continuing Professional Development (CPD) Act was enacted in 2016 "to promote and upgrade the practice of profession in the country ... [and to] ... continuously improve the competence of the professionals in accordance with the international standards of practice, thereby, ensuring their contribution in uplifting the general welfare, economic growth, and development of the nation". Professional update set by most regulatory bodies is an important aspect of professional obligation (Owoeye et al., 2019). With the rapid advancements in the nursing profession and the healthcare industry that is reshaping nurses' role (Acob & Martiningsih, 2018), professional nurses are expected to participate in CPD activities to update their knowledge and skills, increase their competencies and ensure that they remain current and relevant with contemporary practice (Chong et al., 2014;Brekelmans et al., 2016).
However, the implementation of mandatory CPD struggled with some resistance among professionals in the country. An online poll conducted by the PRC Board News (2018) on its Facebook page revealed that 9 out of 10 agreed to repeal the CPD Law. Although a study among Filipino librarians found positive attitude towards deciding to participate in CPD activities (Abrigo & Abrigo, 2017), some prior studies disclosed that many Filipino professional teachers (Bautista et al., 2017) and civil engineers (Orale et al., 2016) were not supportive of CPD law implementation.
important so that nurses can make informed decisions and prevent unintended noncompliance to CPD requirements for license or Professional Identification Card (PIC) renewal. Little research has been conducted regarding CPD in the country. Hence, this study was conducted to determine the awareness of nurses of the CPD law and its IRR as well as their participation in CPD programs and activities.

METHOD
This pilot survey utilized a descriptive research design. The participants were 30 conveniently chosen nurses working in a private tertiary hospital in Iloilo City, Philippines. A researcher-made, self-administered instrument was used to gather data. The items on the survey tool were based on the relevant provisions of the Republic Act No. 10912 or the CPD Act of 2016 and Professional Regulatory Commission (PRC) Resolution No. 2019-1146 series of 2019 or the amended provisions of PRC Resolution No. 1032 series of 2017 otherwise known as the IRR of Republic Act No. 10912. Responses in the 3-point awareness scale range from "not aware" to "highly aware". A higher score indicates higher awareness of the CPD Act and its IRR. Participants were also asked about the types of CPD activities that they have participated in within the last 12 months. A personal data sheet was used to gather certain demographic and work-related profiles of nurses. The instrument was content validated by three (3) jurors. The internal consistency of the tool revealed an acceptable level of Cronbach's alpha > .70.
The pilot study protocol was approved by the Research Ethics Review Committee of the hospital (HOSPITAL-StR-01-09). Administrative clearance to conduct the survey was obtained from the Hospital Administrator and the Chief of Nursing Service Division. Informed consent was obtained from the study participants before actual data gathering. The survey was conducted in the second quarter of 2019. Survey forms were distributed in a sealed envelope at the most convenient time for the participants.
Percentage, frequency, mean, and median were used to describe the data. Mann-Whitney U test was used to examine for differences between variables. Data analysis was aided by SPSS version 23.
Previous studies have shown that CPD participation of nurses is challenged with several barriers (Aboshaiqah et al., 2012;Macaden et al., 2017;Mosol et al., 2017;Ingwu et al., 2019). On the other hand, nurses' perception of the importance of CPD activities was found to be a key factor influencing their CPD participation (Brekelmans et al., 2016). Nevertheless, the lack of awareness during change continues to be a top contributor to resistance among those affected by the change (Nevenhoven, 2016). For instance, the limited awareness about the new CPD Act among nurses may contribute to their lack of support to CPD Act implementation. Awareness allows someone to become proactive rather than reactive to circumstances (Harrison, 2020). Having awareness and adequate information about the CPD law is Table 1 shows that majority of the participants who participated in the survey were females (56.7%), single (90%), and with a staff nurse or non-supervisory position (73.3%). All (100%) were with permanent or regular status of employment.  Table 2 shows that nurses were moderately aware (M=2.31) of the CPD law and its IRR. None of the nurses were unaware that the CPD Act of 2016 is a law that requires all Filipino professionals including nurses to participate in CPD programs, that CPD means the inculcation of advanced knowledge, skills and ethical values in a postlicensure specialization, that CPD is a mandatory requirement in the renewal of the PIC and that an accredited program should be accredited by the CPD Council.

Level of awareness of nurses of the CPD law and its IRR
However, more than half were not aware that authorship of books and news articles and educational videos are examples of activities under the Self-Directed CPD (70%), that seminars or trainings undertaken abroad conducted by nonaccredited CPD Providers may be accredited through Self-Directed Learning (SDL) (60%) and that nurses can earn CPD credit units through online CPD programs offered by an accredited CPD provider (56.7%).
A little more than one fourth (26.7%) were not aware that examples of structured CPD activities include seminars, workshops, trainings, and conferences, that nurses are required of not more than 15 credit units prior to renewal of PIC and The youngest was 23 and the oldest was 35 with a median age of 27 years old. The median monthly salary was PhP 12,000 with the lowest receiving a monthly salary of PhP 8,000 and highest earning PhP 18,000 monthly. The median years of work experience in the hospital was 3.5 years with a rangeof 1 to 14 years. Salary (Mean = PpP 12,000; Median = PpP 12,000) PhP 15,000 to PhP 18,000 10 33.3 PhP 8,000 to PhP 12,000 20 66.7 Almost half (47.7%) were not aware that excess CPD cannot be carried over to the next three-year period and more than one-third (40%) were not aware that only completed post baccalaureate degree programs can be used to earn CPD credit units.

Table 2 Level of awareness of nurses of the CPD law and its IRR
Authorship of books and news articles and educational videos are examples of activities under the Self-Directed CPD. Seminars or trainings undertaken abroad conducted by non-accredited CPD Providers may be accredited through Self-Directed Learning. Nurses can earn CPD credit units through online CPD programs offered by an accredited CPD provider. Excess Credit Units cannot be carried over to the next three-year period. Only completed/graduated post baccalaureate degree programs (Masters or Doctorate) can be used to earn CPD credit units. Examples of structured CPD activities include seminars, workshops, trainings, and conferences. During the transition period of CPD Act of 2016, nurses are required of not more than 15 credit units prior to renewal of Professional Identification Cards (PIC). Seminars, workshops and conferences not approved by the CPD council may be applied for credit units under Self-Directed and Lifelong Learning. There is a CPD Council that regulates CPD programs for nurses. Fraudulent acts relating to the implementation and enforcement of the RA 10912 is punishable by law. CPD Providers and Programs should be accredited by the CPD Council of Nursing. Government agencies and organizations employing professionals shall include the CPD as part of their human resource development plan and program. CPD Council of Nursing grants CPD units for the different CPD Programs. In-house training programs and capacity-building activities of government agencies and private employers shall be accredited and considered as CPD compliance of their employed professionals. Private firms and organizations employing professionals shall include the CPD as part of their human resource development plan and program. CPD Programs consist of activities that range from structured to non-structured activities. Individuals, groups, and organizations may apply for accreditation to become a CPD Provider. Registered and licensed professionals shall complete the required credit units every three (3) years of compliance period.     Table 4 shows the different types of CPD activities and programs attended, participated, or taken by nurses in the last 12 months. It can be gleaned in Table 4 that the most common CPD activities participated by majority of nurses were seminars with approved CPD credit units (83.3%) or without approved CPD credit units (90%) and workshops with approved CPD credit units (63.3%) or without approved CPD credit units (70%).

DISCUSSION
This research assessed nurses' awareness of the CPD law and its IRR as well as their participation in CPD activities. This study demonstrated that nurses were generally aware of the CPD law and its IRR. The moderate awareness of nurses included in this study may have been a result of the information dissemination campaigns on CPD law from the time of its passing in 2016. Unsurprisingly, nurses in this survey understood what CPD and the renewal requirements of the CPD Act of 2016 are. Similarly, nurses in other countries also understand the concept of CPD and recognize that mandatory CPD will improve nursing care and will keep their knowledge and skills up-todate (Yfantis et al., 2010;Ingwu et al., 2019).  However, while all nurses in this study were aware of the law that mandates Filipino nurses to take CPD credit units prior to the renewal of their PIC, it is significant to note the many nurses do not have an awareness of learning activities under SDL. According to the CPD Act, CPD refers "to the inculcation of advanced knowledge, skills and ethical values in a post-licensure specialization or in an inter-or multidisciplinary field of study, for assimilation into professional practice, self-directed research and/or lifelong learning". Moreover, according to the law, SDL refers "to learning activities such as online training, local and international seminars/nondegree courses, institution/company sponsored training programs and the like, which did not undergo CPD accreditation but may be applied for and awarded CPD unit by the respective CPD Council". O'Shea (2003) , 2003). A review study also found that unique factors affect nurses' SDL (Chakkaravarthy et al., 2018). The authors proposed that a personalized SDL program must be developed based on nurses' personal characteristics (Chakkaravarthy et al., 2018). Nonetheless, nurses in the country must be made aware of what constitutes SDL as defined by the CPD Act. Moreover, it also appears that in this study, online CPD programs were not a popular platform for the delivery of CPD activities among Filipino nurses. Possibly, this is because SDL and online CPD are new features in the provision of CPD in the Philippines compared to traditional structured ones like seminars and workshops. Similarly, workshops were found to be the most popular CPD activity among Malaysian nurses (Chong et al., 2014), while conferences, workshops, and seminars were the CPD activities commonly attended by nurses in Western Kenya (Mosol et al., 2017). Attendance at conferences and trainings were also the preferred modes of CPD among Indian nurses (Macaden et al., 2017). Despite the fact that online CPD activities are not well known to nurses in this study, it has been found and suggested in other countries that nurses are positive about online learning opportunities (Karaman, 2011;Chakkaravarthy et al., 2018), and that provision of online CPD may improve or maximize access to CPD among nurses (Ousey & Roberts, 2013).

Types of CPD
Opportunities for online CPD learning programs may be explored within the Philippine context.
Additionally, there were some nurses in this study who were unaware that nurses are only required of not more than 15 credit units prior to the renewal of their PIC. This possibly may be due to the fact that the survey was conducted a few months before the release of the new IRR of CPD law through PRC Resolution No. 2019-1146 series of 2019. In the earlier version of the IRR, professional nurses were required of 45 credit units prior to the renewal of their PIC. Under the new IRR, the PRC relaxed the requirements for license renewal during the transition period.
Furthermore, earlier research found that lack of awareness of educational opportunities and lack of relevance of Continuing Education were considered barriers to CPD participation among nurses (Penz et al., 2007). Among those affected by the change, limited awareness about the proposed change is linked with refusal to accept it (Nevenhoven, 2016). It is recommended that information dissemination and awareness campaigns should be continuously deployed to overcome incorrect information and assumptions about the CPD law.
The finding of this study also showed no variation in the awareness of nurses when grouped according to certain demographic and work-related characteristics. Nurses in this particular hospital may have been given similar information about the CPD law. In addition, no significant variation in nurses' awareness in this study may be attributed to the relatively limited sample size of the study. The nurses included in this survey were generally young, not older than 35 years old. These nurses belong to the millennial generation and are believed to be the largest cohort in the current nursing workforce (Lamasan & Oducado, 2018). Attention must be given to younger nurses, like new graduate nurses, as they were found to have limited CPD participation (Ubas-Sumagaysay & Oducado, 2020).
Since this is only a pilot survey involving a relatively small number of nurses in one hospital and the CPD law is still in its transition period, findings are preliminary and are not conclusive. Changes in the IRR and standard operating procedures of the CPD law implementation may still be made after this survey. Future researchers may conduct a similar study in a larger sample and may embed qualitative data in the research design.

It i
The findings of this research indicated that professional nurses included in this study are generally aware of the CPD law and its IRR, although gaps in the pr isions of the law were identified. It is hoped that addressing the knowledge gaps regarding the CPD law identified in this study may assist in reducing resistance in the implementation of the mandatory CPD among nurses. s suggested to invest in continuous information campaigns and regular updating to overcome incorrect information and assumptions about the CPD law.