• There is a growing awareness that knowledge, skills and attitudes acquired in training are not making their way into nursing practice.
• Nurses experience different influencing factors in their continuing professional development.
• Educational activities often do not meet the needs of nurses and should be more linked to practical application and patient outcomes.

• That nurses should learn how to learn, to learn how they could use their workplace to integrate learning (e.g. workplace learning) and mandated training should only be offered when aims and expectations of the training are clearly defined.
• That educational expert should be involved in the design of the educational activities provided to nurses and along with nurses and managers they should define aims and expectations prior to the training.
• That workplaces need to reflect values and beliefs about the importance of learning and supervisors need to express expectations that nurses are accountable to use the skills and knowledge in their practice.

There is a growing awareness that knowledge, skills and attitudes acquired in training are not making their way into nursing practice, also known as the knowledge-to-practice gap [1]. Bridging this gap requires a ‘transfer of knowledge’ to the workplace in which nurses are able to apply the acquired knowledge, skills and attitudes in their job, which should lead to meaningful changes in performance [2]. The dynamic transfer model describes transfer as a dynamic process that unfolds over time. It includes several phases and personal (e.g. motivation), training-related (e.g. design) and contextual (e.g. supervisor and peer support) influencing factors [3]. At the beginning of the transfer process a trainee evaluates the developed knowledge, skills and attitude (KSA) and forms intentions to transfer [4]. This is an important phase as the trainee decides to maintain or discard their KSA, which results in the stop or continuation of the transfer process. This study focuses on motivation to training transfer during the first phase in the transfer process. 

The relevancy of the study lies in former research showing that nurses experience different influencing factors in their continuing professional development (CPD) [4]. For example, negative influencing factors due to nurse shortages, clinical care dynamics and the mismatch between educational activities and nursing practice. Educational activities often do not meet the needs of nurses and should be more linked to practical application and patient outcomes. Furthermore, most nurses learn more effective through workplace learning, while in current practice nurses often need to leave their workplace to participate in educational activities in classrooms [4]. Finally, Healthcare organizations invest a lot of time and money in educational activities for nurses, but because of a lack of follow-up evaluations of educational activities there is little evidence how educational activities can improve patient outcomes or how theoretical knowledge is applied in practice [5]. This relates to the so-called transfer problem which refers to the concern whether investing in training also leads to a return an organization can expect, for instance improved patient outcomes [6].

Given the previously discussed knowledge to practice gap, the transfer problem, and the urgency to bridge this gap, this paper describes the challenges in motivation to transfer training to nursing practice through the lens of a case study, aiming to provide critical insights to reevaluate the way educational activities are organized in nursing practice.

Research shows that motivation to transfer training is essential for training transfer and is defined as “the trainee’s desire to use the knowledge and skills” [7]. Motivation is influenced by factors pre-, during and post- training regarding individual, training-related and organizational factors, which are described in the Integrative Model of Motivation to Transfer Training (IMMTT, Figure 1) [7]. 

Figure 1: Integrative Model of Motivation to Transfer Training.

A single case study design was chosen to illustrate motivation to transfer training in nursing practice. The constructs described in the IMMTT were used during data collection [7]. Data was collected during three moments in time: 1) pre-training, 2) during training, 3) post-training (Figure 2). For all methodological aspects of this study see (Table1, Appendix 1). Data collections started in October 2022 and were analyzed using thematic analyses [8].

Figure 2: Data collection during three moments in time.

Appendix 1: Methodological overview case study.

Appendix 1: Methodological overview case study.

Motivation to Transfer Training To Nursing Practice-The Case

This paper describes the knowledge transfer process through the lens of a case study, the case of Nurse Carol. Since 2004, Carol works in a tertiary teaching hospital in the Netherlands. During her career she has worked on mainly chirurgical wards. Since 2020 she is a specialized nurse in obstetric care. The change in her career was driven from the fact that her youngest daughter started at elementary school which resulted in more spare time. Furthermore, there were various reorganizations in a short period of time at her ward which resulted in the start of a new manager who she did not like. At that moment there was a job vacancy for an obstetric nurse, a long desired whish for which she also hesitated, because she wondered whether she had sufficient competencies. She decided to take her changes and applied for the job for which she was hired. As part of a professional development program for nurses at her ward she attained a mandatory coaching training, because she is one of the nurse leaders of a working group that focusses on the professional development of her nursing colleagues on her ward.

One week before the training started Carol had not yet thought about what she wanted to achieve with the coaching training. She did not set a learning goal for herself. All nurses who participated in the training received an email with a survey in which they could indicate their learning goals and describe a case from their practice. Carol, as several other nurses, did not fill in the survey, she was too late.

Carol: It’s always super busy at our ward. You barely have time during working hours to think about anything else than your work. You barely have time to take a break. And people are then also not so inclined to do additional things [e.g. prepare for training], because they feel they don’t have any time or energy left anymore.

Her effort and performance expectations of the training were low. Leading up to the training there have not been any discussions about the aims or expectations of the training.

Carol: You are only allowed to participate in the training if you actually want to do something with it later on [referring to a statement the supervisor made]. …but that does put off a lot of people. They immediately see that as something really big you have to do then. That is deterring people from taking that training course.

During a well-designed training which included transfer promoting elements (for description of training design see Appendix 2), Carol set a goal for herself. She wanted to learn how she could keep the goal in mind at the beginning of a feedback-conversation with a colleague and leave emotions out of this conversation. Directly after the training, Carol evaluated the training positive, it included a lot of practice-oriented cases and she learned a lot. During the second interview, one month after the training, Carol could not remember the learning goal she set for herself. Transfer did not occur. We evaluated possible influencing factors on her ward.

Appendix 2: Description of training design (written notes of the researcher).

Joint opening in circle, Duration 42 minutes Coach is part of circle while sitting. Time is taken quietly to discuss matters. The trainer consciously mentions this and wants to create safety and trust. Experience and knowledge is shared. Refresh. Many nurses have not received the homework assignment. It appears to have ended up in the spam mail. Part of the homework assignment was: what did you take away from part 1? What do you use? What are you running into? What's going well? What not? And share a case. A circle is made; nurses share their color and express their expectations for the training. What do you want to learn? The coach asked if the nurses prepared cases. With the retrieval of this information, the knowledge is also refreshed; what were the characteristics of the colors again? There are substantive discussions about each other's colors (do you recognize them in someone else?) and qualities of each other. Coaching 1 has created awareness about the colors and how to give each other feedback (based on colors) and the awareness to develop qualities of other colors. Carol indicates in the group discussion that the diversity in colors is more open for discussion at the ward (that is a 'red' reaction). She states as a learning goal that at the beginning of a feedback conversation she wants leave the emotions out of it.

Second round (after rounding off circle). Duration about 45 minutes. The nurses remain in a circle and the coach stands next to a flipchart. During this round, theories and models are discussed; knowledge is collected and shared again. Mainly based on cases the nurses’ share. The knowledge of coaching 1 has partially subsided. The nurses no longer know what certain models and theories looked like or should be applied. Carol shares a case about giving feedback to a student. Role plays are played (coach plays student, Carol gives feedback). This is jointly evaluated. Models and theories are discussed how this can best be approached step by step. Main learning objective: ask more questions, keep it small and celebrate more. To conclude, the process is briefly summarized and the nurses can ask questions.

Break +/- 15 minutes; a number of nurses linger at the coffee machine and discuss a case with each other again. Carol does not participate in this.

The third round starts again in the circle. Duration 70 minutes. The coach asks whether the theory booklet that all nurses have received is useful. The coach draws the circle of influence on the flipchart. Again a case is shared about coaching a colleague who has no request for help. The coach has depicted Leary's rose on the floor with tape and asks the nurses to stand up and gather around the rose. First theoretical explanation about the four subjects. Carol again shares a case about giving feedback to a colleague. Again role play and steps are discussed. Carol seems to find it difficult to receive/apply feedback. In the meantime, the nurses slowly sit down one by one (“tired”, “my back hurts”), but they stay around the rose.

Completion. Duration 10 minutes. Nurses are asked to sit in a circle. The coach asks if there are any questions left. The coach asks to think about what the nurses will take with them in concrete terms, what will you be working on at the ward? Carol indicates that she wants to keep the goal in mind at the beginning of feedback conversations. And wanting to keep everything else out of it (emotions). The coach thanks everyone for their openness. The course is not further evaluated.

First, no further expectations about the application of the training on the ward were discussed after the training between her colleagues and supervisor. The supervisor of Carol did not support, facilitate or stimulate the application of the acquired knowledge and skills at their ward. Second, Carol experienced little support on her ward from her colleagues in the application of the acquired knowledge and skills. Roughly 25% of the nurses on her ward participated in the training. In her opinion, increasing the amount of participants in the training could increase the support and use of knowledge and skills. Third, Carol feels moderately appreciated by her employer. She is disappointed about the lack of financial possibilities and the possibility to work less hours or have additional days off.

Carol: … You’re allowed to work overtime every day and to hand in your breaks every day. But if you need something, you can’t get an extra day off.

Motivation to Transfer Training to Nursing Practice-Critical Analysis

Individual

Educational activities for nurses are often mandatory in order to comply with healthcare regulations. Also, educational activities are frequently provided organization wide, which means that individual needs of nurses are often not considered in the design. At the beginning of the transfer process it is important that nurses feel motivated to achieve a goal, a desired level of achievement, by participating in the educational activity. They need to feel motivated to transfer the acquired knowledge and skills to their practice. The trainee’s role is thus of importance in the transfer process. Research about the influence of mandatory or voluntary training on motivation to transfer training is scarce, but one could expect that the mandatory nature subverts intrinsic motivation and therefore the transfer process. There is however research about the influence of self-regulated learning, goal orientation and self-efficacy on transfer of training. Goal orientation has a positive influence on learning and transfer outcomes [9] and the motivational relationship between self-efficacy (one’s capabilities to achieve a goal) and transfer performance is evident [10, 11]. This requires for nurses to develop skills, such as critical and creative thinking, research awareness and reflection skills [12]. However, in current nursing practice educational activities tend to focus on the acquisition of new knowledge (knows how) instead of its application in practice (does). It is important to reevaluate the necessity of mandatory educational activities for nurses and to promote self-regulated learning competencies among nurses. If important preconditions at the beginning of the transfer process are not met (i.e. motivation to participate, goal orientation, perceived self-efficacy), the transfer process is destined to fail. Recommendations for practice would be to learn nurses how to learn, to learn them how they could use their workplace to integrate learning (e.g. workplace learning). Furthermore, mandated training should only be offered when aims and expectations of the training are clearly defined. 

Training-Related

One can influence the transfer process in a positive way by training-related framing. Framing consists of three elements: 1) determine the status of the training (voluntary or mandatory), 2) providing information about the training prior to the training, 3) offer the trainees the opportunity to provide input [7]. It is important for nurses, managers and educators to know that framing is an important influencing factor in the transfer process, because it can stimulate learner readiness, positive attitudes and transfer motivation [7]. Little attention is paid to this influencing factor in nursing practice, because educational activities are often provided by subject-matter experts who most of the time are not educational experts or are familiar with educational elements that can influence the transfer process. Therefore, recommendations for practice would be to involve educational experts in the design of the educational activities provided to nurses. Educational experts, along with nurses and managers, should define aims and expectations prior to the training.

Organization

The context of the workplace itself is also an important influencing factor, because job characteristics such as workload, perceived autonomy and support, influences transfer motivation [6, 7]. Nurses learn by workplace learning, by puzzling and enquiring, by learning of experiences from themselves and others and they learn from making mistakes [4, 13]. However, in current practice nurses often have to leave their workplace to participate in educational activities. Besides the fact that those educational activities often do not meet the needs of nurses, it is also undesirable in relation to the nursing shortages. Going forward, recommendations for practice would be that learning for nurses should be more focused on workplace learning. Workplaces need to reflect values and beliefs about the importance of learning and supervisors need to express expectations that nurses are accountable to use the skills and knowledge in their practice.

Despite individual needs of nurses in their CPD, there is an existing gap between the way educational activities for nurses are currently organized and on the other hand the common mission nurses, managers and educators have to change this. Organizing educational activities in nursing practice should occur more conscious, in which nurses are responsible for their own learning, managers act as role models and facilitate and support knowledge transfer to the workplace and in which educators support positive learning climates in nursing practice. Together they should be responsible for the transfer of acquired knowledge and skills to the workplace to provide excellent patient care.

Funding Sources: no external funding

Conflicts Of Interests: none

1. Gassas R. Sources of the knowledge-practice gap in nursing: Lessons from an integrative review. Nurse Education Today, 2021; 105095.
2. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W & Robinson N. Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 2006; 26: 13-24.
3. Blume BD, Ford JK, Surface EA & Olenick J. A dynamic model of training transfer. Human Resource Management Review, 2019; 29: 270-283.
4. Hakvoort L, Dikken J, Cramer-Kruit J, Molendijk- van Nieuwenhuyzen K, Van der Schaaf M & Schuurmans M. Influencing factors of continuing professional development over a nursing career: A scoping review. Nurse Education in Practice, 2022; 103481.
5. Griscti O & Jacono J. Effectiveness of continuing education programmes in nursing: Literature review. Journal of Advanced Nursing, 2006; 55: 449-456.
6. Blume BD, Ford JK, Baldwin TT & Huang JL. Transfer of training: A meta-analytic review. Journal of Management, 2010; 36: 1065-1105.
7. Gegenfurtner A, Veermans K, Festner D & Gruber H. Integrative literature review: Motivation to transfer training: An integrative literature review. Human Resource Development Review, 2009; 8: 403-423.
8. Terry G, Hayfield N, Clarke V & Braun V. Thematic analysis. The Sage Handbook of Qualitative Research in Psychology, 2017; 17-37.
9. Dierdorff EC, Surface EA & Brown KG. Frame-of-reference training effectiveness: Effects of goal orientation and self-efficacy on affective, cognitive, skill-based, and transfer outcomes. Journal of Applied Psychology, 2010; 95: 1181.
10. Gegenfurtner A, Veermans K & Vauras M. Effects of computer support, collaboration, and time lag on performance self-efficacy and transfer of training: A longitudinal meta-analysis. Educational Research Review, 2013; 8: 75-89.
11. Lourenco D & Ferreira AI. Self?regulated learning and training effectiveness. International Journal of Training and Development, 2019: 23: 117-134.
12. Konnyu KJ, McCleary N, Presseau J, Ivers NM & Grimshaw JM. Behavior change techniques in continuing professional development. Journal of Continuing Education in the Health Professions, 2020; 40: 268-273.
13. Jantzen D. Refining nursing practice: A grounded theory of how nurses learn to nurse well in the current health care milieu. Doctoral dissertation. 2012.