Originally Published in Nursing Leadership, 21(2) : 1–4 May 2008
In a recent issue of the Canadian Medical Association Journal, the editor called for the establishment of a Canadian Institute of Continuing Health Education (Hébert 2008). The primary concern behind this proposal is dissatisfaction with the current funding of continuing medical education (CME) and its consequences in terms of quality of the educational products and the confidence physicians have in them. The majority of CME is funded by pharmaceutical companies; as reported in the editorial, in 2006, of the $1.45 billion spent on accredited CME in the United States, 60% came from drug companies (Fletcher 2007). The editor maintains that while Canadian statistics are not available, there is no reason to believe the situation is any different in this country. The caterpillar in this cornucopia of riches is that the pharmaceutical companies do not provide this funding from the goodness of their hearts. To quote from the editorial: "In effect, the industry focuses primarily on treatments and treatment-related issues at the expense of the larger therapeutic picture, including quality of care and patient safety not involving drugs, determinants of health, prevention and health promotion and other modalities of treatment" (Hébert 2008: 805). Perhaps the most surprising and welcome observation in the editorial is that "the current system focuses on physicians rather than on interdisciplinary teams. A team-based perspective is essential if our goal is to improve quality of care rather than market share" (Hébert 2008: 805).
As a nurse, more than once I have scanned opportunities to take a Caribbean cruise and receive hundreds of points towards some continuing education target or other. If I were a physician, a drug company would subsidize my trip. In the middle of February, at –20°C, the ethics and value of such an opportunity might well take a backseat to the possibility of sun and fun. I also recall that a couple of years ago I was surprised when a physician colleague questioned the $150 registration fee for a conference sponsored by an organization in which we are both members. He then admitted that he was not used to paying a registration fee because drug companies subsidized most of the meetings he attended. I was not sympathetic, and he acknowledged the underlying problem.
Nursing has not had to deal with control of nurses' continuing education by the pharmaceutical industry. In fact, at times we have looked with envy at the largesse available to medicine to sponsor conferences and hold workshops that, in the vast majority of cases, has not been available to us. I believe that envy has diminished as evidence-based healthcare has taken root and the potential for tainted evidence via the pharmaceutical industry has been identified and acknowledged.
But what about nursing's continuing education enterprise? It's big, diverse, sponsored and delivered by many different sources, unregulated and variable in terms of quality and relevance. It ranges from superb to trivial. Nurses may get continuing education from their employer, from a local college or university, through their professional organization, from specialty nursing and medical organizations or from private educational organizations, to name just some of the sources. A nurse's employer may dictate and provide some continuing education to ensure that its employees are informed of and prepared to deliver new approaches to care in the workplace. A professional organization may offer programs that have obvious value to large sections of their membership. Continuing education divisions of colleges and universities conduct surveys to identify individual courses and programs, such as palliative care, pain management, elements of administration and more, that are of interest to many nurses.
Essentially, the onus is on the individual nurse to determine her or his continuing educational needs and to find sources to meet them. As one might expect, some nurses aggressively and systematically seek out what is available, assess quality and select wisely. Others wait for education to come to them and live with whatever quality they get, while still others use a hit-and-miss approach.
The CMAJ editor believes that continuing education is too important, relative to high-quality patient care and patient safety, to be left to the vagaries of the marketplace and the influence of Big Pharma. According to him, it should concentrate on improving practitioners' performance and thus patient clinical outcomes and quality of care. Continuing education should "focus on themes and topics based on the needs of patients or health professionals; make greater use of a broad range of proven, effective adult learning techniques; include all health professionals, be affordable, accessible and where possible, integrated into clinical practice" (Hébert 2008: 805). To achieve this, he proposes the creation of an Institute of Continuing Health Education that would, among other things, set guidelines and standards, identify gaps, develop and promote interprofessional educational opportunities, develop effective ways of educating health professionals, integrate this education into clinical practice and serve as a clearinghouse for continuing education for all health professionals.
This seems like a good idea in so many ways, perhaps even one whose time has come. However, before elbowing to the front of the line to endorse it, we need to consider a number of things. Nurses' continuing education, while not organized systematically, is not subject to "taint" as CME has become. Do we want national oversight and organization? What indicators are there to suggest we need the organization, standard setting and accreditation that are being proposed? Do we agree with the description of continuing education described in the editorial? I believe nursing holds a more inclusive view that goes beyond the improvement of clinical practice as the only objective. A strong element within nursing continuing education focuses on administration and leadership. The intention ultimately is improved patient outcomes, but these are attained indirectly, through better management of nursing resources. Also, some nurses who do not hold degrees want credit towards degrees from their continuing education undertakings; indeed, some universities have arranged their continuing education offerings to articulate with degree requirements. Would this type of continuing education meet the criteria the proposed institute might set?
The basic questions are: How would such an institute improve upon what is available now? and, Who would pay its operational expenses? From my perspective, the interprofessional element is the most appealing part of the proposal. As we creep towards true interprofessional team-based care (which I acknowledge is flourishing in some settings and has yet to emerge in many others), and as research multiplies the knowledge base of all the health disciplines, it is clear that much of what health professionals need to know to provide care should be learned together. This interrelatedness does not negate the unique aspects of care that each discipline would continue to teach and learn on an intradisciplinary basis. The popularity of interprofessional conferences in cardiology, cancer, aging, neurology, nephrology, bioethics, etc. speaks to the joint interests of the disciplines and practitioners who work together to plan the conferences, present papers at them and participate in the discussions. This is a great base on which to build. The funding is quite another challenge, and one that is not addressed in the editorial. Clearly, the pharmaceutical industry is not an option, unless these companies would be prepared to make a no-strings-attached donation!
The CMAJ editor suggests that the Canadian Academy of Health Sciences (CAHS) take on this challenge and begin discussions with stakeholders. Here I must declare a conflict of interest, as I am a fellow of CAHS and an executive on its board. Nevertheless, I think continuing education is a topic that the interdisciplinary academy is well suited to tackle. It has a number of instruments at its disposal to explore the issues and present a range of options with their strengths and weaknesses.
Nursing should welcome this suggestion from the CMAJ. It raises an important opportunity for all the health disciplines to consider. Thank you, Mr. Editor.
Fletcher, S.W. 2007. "Chairman's Summary of the Conference." In M. Hager, ed., Continuing Education in the Health Professions: Improving Healthcare through Lifelong Learning. Bermuda, November 28–December 1. New York: Josiah Macy, Jr. Foundation.
Hébert, P.C. 2008. "The Need for an Institute of Continuing Health Education." Canadian Medical Association Journal 178(7): 805–6.
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