According to literature reviews, the concept of continuing education refers to training activities that take place after the completion of initial training. It promotes the enrichment and updation of knowledge and the development of skills [14].

As a corollary, Abbatt & Mejia stated “Continuing education encompasses all forms of learning, not just refresher courses, and extends from the end of initial training to retirement. It covers not only knowledge but also a wide range of skills that are directly relevant to the delivery of health care” [2].

There are several reasons for the need for continuing education among nurses. On the one hand, research shows that the knowledge acquired in basic professional education has a half-life of about 2.5 years, and by the end of this period, the knowledge that is not reinforced by continuing education will be outdated or obsolete [15, 16].

On the other hand, this education will expire 5 years after graduation, so the lack of continuing education can lead to a deterioration of services to patients or even their death [16]. The updated CE curriculum can provide nurses with the knowledge and skills that they will need throughout their professional lives [1].

Therefore, it is important to update the knowledge and skills of nurses through continuing education to ensure safe and competent care for the population [15-19].

The rapid and constant evolution of knowledge requires nurses to continuously update their knowledge throughout their scareers, through continuing professional education. In this respect, in the Quebec context, CE has become an ethical obligation requiring nurses to participate in a minimum of 20 hours of continuing education activities annually to maintain their right to practice [1-19].

The nurse has a legal responsibility to keep his or her specific knowledge and skills up to date in terms of the care provided [20, 21].

For its part, the health care institution is obliged to keep the knowledge of its health care personnel up to date by implementing continuing education programs [22]. These programs must include monthly training sessions, annual theme days and should cover one or more aspects related to the advanced specialties of the units concerned [2].

On this basis, continuing nursing education is recognized as a right of all health professionals, regardless of their mode of practice, and a duty of the health institution to which they are attached [17-22]. It is recommended that such an education program should be flexible and related to the specific needs of nurses [2].

Continuing education helps nurses to keep their practice safe and current. Although the literature emphasizes the need to update knowledge and skills and outlines information on motivational strategies and learning styles, little research has been done on the barriers to nurses' participation in continuing education. Certainly, this literature review describes factors that constrain nurses' learning and participation in continuing education activities.

Gibson attributed this finding to several factors, the most important of which were related to work overload, which also negatively influenced nurses' professional development. Other constraining factors noted were related to the lack of time and resistance to change for participation in continuing education activity [23].

However, Santos reported that some of the factors constraining nurses' learning are:(a) the lack of time and inflexible work schedules, (b) organizational culture that encompasses lack of support from managers and colleagues, inability to apply new knowledge in practice, and the risk of being judged by colleagues, and (c) training that are held distant from the workplace and not necessarily adapted to nurses' needs [24].

More recently, and in view of other studies interested in continuing nursing education, the attitude was mentioned as a central theme due to which nurses participated in a continuing professional development program [9-26].

In order of importance, the four priorities that influenced this attitude were communication, continuing professional development, time constraints, and financial implications [26].

In accordance with the studies conducted by Shahhosseini & Hamzehgardeshi, it was proposed that the mean score of facilitators for nurses' participation in continuing education was significantly higher than the mean score of barriers.

Moreover, the highest mean score among the facilitators of nurses' participation in continuing education was related to “Update my knowledge”. In addition, the highest mean barrier score from the participants' perspective, in three personal, interpersonal, and structural domains, was related to “time constraints”, “lack of support from colleagues” and “professional commitments” [16].

On another niche, Eslamian, Moeini & Soleimani showed that the current approach to nurse CE needs to be changed to meet their needs. Therefore, education management and planning should be based on a new approach that focuses on nurses' needs.

In addition, attention should be paid to problems related to inadequate facilities and faulty assessments during CE sessions. In other words, nurses' practice should be supervised after training to determine whether or not the educational objectives have been met [11].

In contrast, in a literature review, Gopee mentions important aspects of the factors facilitating lifelong learning according to the following categories: individual (or personal), organizational and socio-political [9].

The individual or personal factors that have been highlighted by both Gopee and Timmermans et al. show that there is a relationship between positive attitude towards learning in the workplace, whether in groups or individually, an appreciation of teamwork, and an interest in continuous improvement [9-25].

Thus, workplace learning is a major challenge for healthcare organizations, which cite staff shortages, the time required for training, and budgetary constraints as factors that make workplace professional development more complex [27].

However, organizational factors that facilitate nurses' participation in continuing education programs mentioned Gopee are the requirement for continuing education hours by professional bodies, budget allocated to continuing education, time off available for those who engage in continuing education activities, career development opportunities, on-the-job learning and changes in teaching methods [9].

Similarly, the institutional factors discussed Gopee are learning organization, managers focused on clinical supervision, reflective practice, and peer review as strategies to maintain competencies. At the societal and governmental level, factors are related to favorable attitudes towards training, budget allocation, and promotion of training through policies that influence development [9].

The analysis of the literature has enabled us to construct our conceptual frame of reference (Fig. 1). This conceptual framework constitutes a schematic representation of the factors hindering the participation of nurses in CE sessions, which in turn groups together three sub-difficulties, individual (or personal), organizational and institutional. Arrows illustrate the factors that can affect each other. However, some of the components of these difficulties could be either placed in one set of groups or several groups.

The study was conducted at nine prefectural or provincial Hospital Centers (HCs) in the Casablanca-Settat region during March, April, and May 2018.

A random selection was made of the various prefectural or provincial hospitals in the Casablanca-Settat region out of the 15 hospitals; (N: 1462 nurses) and some criteria were established, namely bed capacity, specialty, geographical area, population served, and reference level. Subsequently, after the random selection of nine hospitals, the study involved all nurses practicing and providing care, therefore, cluster probability sampling technique was used. The sample size was set at (n¹: 1115) (i.e., 76.26% of the total population).

The data collected will be supplemented by nine semi-structured interviews (n²:09) with those responsible for continuing education. Thus, the target population will consist of two categories:

n¹: the nursing staff;

n²: those responsible for continuing education

The target population is therefore:

n= (n 1 + n 2 ) = 1115+09=1124

Given the nature of this study, which aims to describe information on the factors hindering nurses' participation in continuing education sessions, a questionnaire was found to be useful. For this purpose, the questionnaire was developed mainly based on the models proposed by Gopee (2005), Milhomme & Gagnon (2010), Hamzehgardeshi & Shahhosseini, (2014), and by Eslamian et al. on facilitating and hindering factors of continuing education in nursing. These models posit several determinants that may have a significantly positive or negative influence on adherence to continuing education sessions [9-11, 16]. The questionnaire was distributed by the principal author of this study to n¹ =1115 participants from the different HPCs. The sample that answered the questionnaire consisted of 930 participants (83.40%).

Fig. (1). Conceptual framework of factors hindering the participation of nurses in continuing nursing education activities.

The questionnaire was constructed according to the steps described by Fortin [28]. The questions were formulated in such a way as to respect the conceptual frame of reference of the study. To this end, the questionnaire is composed of two principal parts:

(a) The first part aims to find out the general characteristics of the respondents (age, sex, seniority in the service, seniority in the profession).

(b) The second part is composed of several questions related to different factors hindering nurses' participation in continuing education sessions, as identified in the frame of reference of this study. These factors are (a) individual (or personal), (b) organizational, and (c) institutional.

The questionnaire contained (a) closed multiple-choice or semi-open questions. According to Fortin, these types of questions are simple to use and easy to code and analyze, and (b) a few open-ended questions with free responses. The questions are arranged so that the closed-ended questions precede the open-ended ones [28].

The questionnaire was examined before use by a group of experts, who were not involved in the study, and a pre-test was carried out with nurses with the same characteristics as the population under study, who were not part of the sample to judge the relevance of the questions, their degree of comprehension and their ability to provide the required information. This pre-test also allowed us to estimate the time required to complete the questionnaire. Indeed, we can admit that the construct validity of the administered questionnaire could be considered as established.

For the reliability of the questionnaire, we carried out tests and pre-tests with a panel of nurses, having 15 participants. The results obtained showed stability of 91.3%.

The principal author of this study conducted semi-structured interviews with those responsible for continuing education in the various hospitals, based primarily on the theoretical model of the Continuing Education Standards cycle proposed and adopted by the Moroccan Ministry of Health in 1990. This cycle contains five essential steps, namely:

• Diagnosis of Performance,
• Planning,
• Programming,
• Execution,
• Monitoring and evaluation

In this cycle, CE activities are planned logically and sequentially in which the authors describe the elements of educational activity as part of a “system”. The interest of this interview lies in the completion and explaination of the data collected through the questionnaire and also to obtain their point of view on the course of the training session and to share possible suggestions to enhance the participation of nurses in CE sessions. In our interviews, we evaluated the variables mentioned above following our reference model.

We used direct contact with the interviewees. Before interviewing them, information about the aims of the study was established, consent was obtained and permission to take notes or record the interviews was obtained. The continuing education manager interview guide was tested with those responsible for continuing education in hospitals with the same characteristics as the study settings. It consists of four distinct parts:

• Personalized identification of the responsible for CE: gender, age, grade, profile, function, seniority, place of work;
• Variables related to the pedagogical process: identification of needs, planning, programming, execution, monitoring, and evaluation;
• Variables related to the factors hindering nurses' participation in CE sessions;
• Two open-ended questions were included to generate suggestions and recommendations that could contribute to improving nurses' participation in CE sessions.

In effect, these interviews helped to complete and explain the data collected by the questionnaire. The time interval for each interview was scheduled between 20 and 30 minutes.

The data collection process was spread over two phases:

(a) The first concerned the questionnaires for the nursing staff that was spread out during March, April, and May of the year 2018.

(b) The second phase involved nine semi-structured interviews with those responsible for continuing education. These interviews were conducted during May.

The treatment of the data related to the questionnaire is based on the description of the frequencies and percentages of the different categories covered by the variables of the study. The association between the demographic and professional data and the individual, organizational and institutional factors was tested with a Chi-square analysis (p < 0.05). For this purpose, data were entered into an Excel file and then analyzed using SPSS statistical software. The results were presented in tabular form to visualize frequencies and percentages.

For the interview data, a thematic content analysis was performed (Fortin, 1996) which consists of:

• Gathering data on all the themes put forward by the participants;
• Identifying categories of this content;
• For each item, the principal idea is raised and sometimes faithfully transcribed in the form of verbatim;
• Grouping and classifying the information to complete the data from the questionnaire.

The study was carried out after the approval of the directors of the various hospital centers in the Casablanca-Settat region. Participants' consent was also obtained. They were reassured that their answers would remain confidential and their identities would not be revealed in research reports and publications.

The analysis of the statistical data indicates that gender has a significant effect on the organizational factors with a p = 0.000 (in a proportion of 50% of the participants).

However, there was an absence of a statistically significant relationship between gender and the different variables of individual and institutional factors (with a p = 0.05) (Table 2).

The analysis of the statistical data indicates the presence of a statistically significant relationship between age and all the individual (or personal), organizational and institutional factors with a p = 0.000 (respectively in a proportion of 40%, 50% and 56% of the interviewees) (Table 3).

Therefore, it can be concluded that age has a significant effect on the different factors hindering the participation of nurses in continuing education sessions with a p < 0.05.

The analysis of the statistical data indicates the presence of a statistically significant relationship between seniority in the profession and all the individual (or personal), organizational and institutional factors with a p = 0.000 (respectively for a proportion of 40%, 50% and 56% of the participants).

We can, therefore, conclude that seniority in the profession has a significant effect on the factors hindering nurses' participation in continuing education sessions with a p < 0.05.

The analysis of the statistical data shows the presence of a statistically significant relationship between seniority in the service and all the individual (or personal), organizational and institutional factors with a p = 0.000 (respectively in a proportion of 40%, 50% and 56% of the participants). We can, therefore, conclude that seniority in the service has a significant effect on the factors hindering nurses' participation in continuing education sessions with a p < 0.05.

Content analysis of the qualitative data collected from those responsible for continuing education identifies factors inherent in nurses' non-participation in continuing education sessions.

The interviewees stated that a structure is followed for carrying out all the steps of the CE standards cycle, from the determination of the needs of nurses in CE to the follow-up and evaluation of CE activities.

At the beginning of the interview, one of the interviewees stated his positive perception of the Needs Analysis Identification by relating to “the needs analysis is a primordial step to ensure the planning of continuing education. However, “this step of diagnosing the problem and identifying training needs, as described by the 1999 National Continuing Education Standards, has been skipped.”

Also, another interviewee revealed that “the training needs analysis is perhaps the most important function of a C.T. system. Without a needs analysis, there is no way to know if C.T. is relevant or useful.”

Another interviewee added that “ministerial instructions and new developments in health programs constitute an overlap of activities that prevent a precise focus on the real CE needs of nurses, and as a result, we are forced to apply CE sessions that respond to strategically established institutional needs and not to the needs felt and declared by the health professional.”

Various interviewees (5/9) reported that “planning and programming are essential steps in the CE cycle, which should normally be carried out in collaboration with the different actors.”

Also, the interviewees were unanimous in stating that “the planned and programmed CEsessions are not carried out because of the deficiencies noted at the various stages of the process about weaknesses at the organizational level, in terms of lack of human, material and financial resources and the absence of identification of actual needs before the development of CE action plans.”

In addition to this, there were problems related to the teaching methods and materials, and the methodologies adopted were not attractive, therefore, the transfer of skills after the training sessions was insufficient.

Similarly, an interviewee stated that “a large number of programmed sessions were not preceded by the setting of objectives to be achieved, which makes the realization of these sessions difficult, sometimes impossible, and the monitoring and evaluation of skills and performance non-existent.” In such a context, it becomes difficult to obtain a measure of the impact of training activities on those who participate in them and on the organization that initiates them.

Various interviewees (5/9) mentioned that “execution is also the most significant step to reach the objectives of the CE. However, the scarcity of means is an obstacle to the realization of the programmed sessions.” According to the interviewees, these obstacles are related to the lack of coordination of the different actors between all the stages of the process of carrying out CE sessions, the problem of financing CE activities initiated at the local level, the absence of documentation units and the lack of continuing education in pedagogy and andragogy for the trainers.

One of the most striking words of an interviewee was “even we, as responsible forCE,must have training in the engineering and management of the CE cycle in order for CE activities to be successful.”

The interviewees were unanimous in stating that “monitoring and evaluation initiatives are still rare in order to measure the gap between the sessions that were scheduled and those that were carried out. Evaluation is necessary in order to have benchmarks on the approach used during the programming and execution of CE sessions, as well as on the means used in order to take corrective measures.”

One of the interviewees stated that “there is a total absence of evaluation during and after continuing education. Conducting a continuing education evaluation is not always considered due to lack of time. As a result, the evaluation of all the stages has never been done, which highlights the importance of this stage in order to identify constraints and correct them.”

In the same perspective, the different interviewees put forward another factor of primary importance, which is the lack of regulations governing the continuing education of nurses.

On this point, another interviewee announced “that in addition to the absence of a regulatory basis, there is even a legal vacuum to encourage health professionals to participate in CE sessions; based on this observation, the presence of personnel is not mandatory due to the lack of a regulatory provision requiring them to attend CE sessions”

Indeed, those responsible for education suggest that “first of all, a revision of the methodology used for the diagnosis of continuing education needs indicate that a legal basis should be provided for the continuing education of health professionals,” the institutionalization of CE is a guarantee of commitment in all CE sessions. It is also important to make sure that the available pedagogical materials are adapted according to the training needs and the public. Also, there is a need to ensure an accompaniment and a follow-up and evaluation for all the stages of the cycle of the continuous training.

Finally, there is a need to rely more on modern strategies and technologies, especially e-learning platforms. Indeed, the implementation of these proposals remains essential to ensure the participation of nurses in CE sessions in hospitals.