Predictors of health professionals’ satisfaction with continuing education: A cross-sectional study

Objectives: to verify which organizational, methodological, and resource-related characteristics of Continuing Health Education (CHE) help to best predict the professionals´ satisfaction. Method: a cross-sectional study with multivariate logistic regressions to predict a high mean satisfaction with different dimensions of educational actions used: Overall satisfaction, Utility, Methodology, Organization and resources, and Teaching Capacity. 25,281 satisfaction questionnaires have been analysed completed by health professionals attending 1,228 training activities in Andalusia (Spain), during the period from March 2012 to April 2015. Results: the characteristics that best predict a high overall satisfaction are the following: clinical session type as opposed to the workshop (Odds Ratio [OR]=2.07, p<0.001); face-to-face attendance modality (OR=3.88, p<0.001) or semi-personal-attendance (OR=2.83, p<0.001), as opposed to e-learning; and 1-2 days in duration (OR=2.38, p<0.001) as opposed to those of between 3 and 14 days. A lower number of hours (OR=0.99, p<0.001) and a lower number of professionals (OR=0.98, p<0.05) also increase the probability. Having the educational actions accredited increases the probabilities in the following dimensions: Utility (OR=1.33, p<0.05), Methodology (OR=1.5, p<0.01) and Teaching capacity (OR=1.5, p<0.01). Conclusion: the study provides relevant information on aspects that improve professional satisfaction, such as that e-learning activities should improve their content, teaching methods, and styles, or that face-to-face clinical sessions are the type of CHE with the greatest satisfaction.


Introduction
Continuing education is the group of educational activities designed to maintain, develop or increase knowledge, skills, and the performance of active professionals (1) , with it therefore being differentiated from other stages of education, such as degree education, specialized education and post-graduate education. This is an essential and strategic tool to improve quality in health systems (2) , to improve results in the health of patients (3)(4) , to satisfy health professionals (5)(6) , and to transfer and exchange knowledge (7)(8) .
Various systems of accreditation of continuing education have been developed, at the international level and addressed towards health professionals (9)(10)(11) , in order to guarantee the quality level of the educational actions that are performed, by means of the periodical updating and continuous improvement of models (12)(13) .
Since the year 2003, the Andalusian Agency for Healthcare Quality (Agencia de Calidad Sanitaria de Andalucía, ACSA) has implemented a model for accreditation of continuing education activities of health professionals (14) , in consonance with the quality strategies of the Andalusian Health System (15) and with the National Continuing Education Committee criteria. It is structured in quality elements related to aspects such as the need that justifies the education, the characteristics of the teaching-learning process that is to be carried out, the profile of the professionals participating in the education, the resources used in its planning and development, and the results of the educational process. The assessment of these elements determines the degree of quality of the education designed, and, with this, the accreditation or non-accreditation of the educational action in question.
In addition, within the educational activities   (17)(18)(19)(20) . In addition, international models of accreditation of continuing education consider specific standards for the modality of e-learning (21) .

Documents such as Training Evaluation Field Guide:
Demonstrating the Value of Training at Every Level (22) recommend integrating various systems of evaluation  (24)(25) . In order to facilitate standardized instruments for users that allow for the evaluation of given aspects related to the design and development of the educational activities carried out, ACSA created a tool named "eValúa" (26) , in which various online questionnaires are included and which allows for the data collected through them to be processed.
The questionnaire on the satisfaction of professionals included in eValúa is a tool that has been validated (27) and developed taking into account the criteria established in the ACSA accreditation programmes (28) that is designed Taking some studies into account (29) , the educational modality used (face-to-face learning, blended learning, www.eerp.usp.br/rlae properties of reliability and validity of the questionnaire have already been analysed, and improvements have been incorporated (27) .
The study group consists of a random, non-stratified  Table 3).
Given that the dependent variables (DVs) of the model did not comply with part of the criteria to do a least squares regression (homoscedasticity, residual normality, and autocorrelation), it was decided to dichotomize the DVs to be able to launch five logistic regressions. Due to high mean scores in all of the DVs, all of the educational activities that are over the median have been considered as "high scores" while those that are below the median were classified as "low scores".
Therefore, the logistic regressions try to predict a "high score" using the independent variables.

Results
In In Table 2  In Table 3 Finally, when observing the effect of accreditation, the activities have almost 33% more probabilities to be highly valued in relation to their Utility, and 50% more in relation to their Methodology and to their Teaching capacity.

Discussion
The The results presented herein are consistent with those found in previous studies that showed lower professionals' levels of satisfaction with e-learning activities with regard to the methodology used (17,30) , the capacity of response by the teacher, and the suitability of the education for the educational needs of the professionals (5,30) . Nonetheless, those are advantages that were traditionally attributed both to online education and to semi-personal attendance education, or blended learning, such as flexibility (31) , anonymity in the platforms that facilitate participation, or the greater availability to be able to combine this with personal life and work (32) .
Recent studies found either low or very low evidence that e-learning education may have any effect on behavioural changes in health professionals or on patients' outcomes (32)(33) . Nevertheless, due to the continuous development of software tools that allow for online education to be carried out in a more personalized way, such as adaptive e-learning (34) , and the advantages that these courses allow for in support of educational self-management (17) , it may not be ruled out that further investigation in the subject area and further innovation in the training programs alignment with the real needs of professionals may improve the results obtained to date (6) .
Another of the most important findings is related to the differences found depending on the type of education.
Previous works have shown the utility and acceptability of interdisciplinary clinical sessions or conferences in the health area (35) . Their organization, which is often of the personal-attendance form in the same health centres in which the professionals perform their work, as well as a methodology focused on very specific objectives, tend to be highly-valued aspects (36)(37) . However, in spite of the importance of clinical conferences in the improvement of interdisciplinary communication (38) , there is a need to improve the pedagogical skills of teaching professionals (39) . The results obtained have reconfirmed both points since clinical conferences are more likely to be highly valued as regards their methodology and form of organization, but less in relation to the capacities of the teaching professionals.
In spite of the fact that, in her study, Hall found no solid evidence on the impact of the duration of the education -whether this may be measured in hours or spread over days -in relation to the satisfaction level perceived or to the acquisition of knowledge (40) , in the current study a slight trend has indeed been observed in the sense that the lower the number of hours, the greater the general satisfaction level, with www.eerp.usp.br/rlae 7 Munoz-Castro FJ, Valverde-Gambero E, Herrera-Usagre M.
such education being concentrated in a shorter period of time. The evidence has shown that the acquisition of knowledge by professionals in continuing education decreased slightly as the number of attendants at the course increased (41) . The results presented here sustain this hypothesis because, as the number of professionals in educational activity increases, the overall mean satisfaction levels with the utility, the methodology, and the teaching capacity, decrease.
Finally, the possible future effect of accreditation on the satisfaction of professionals was also considered.
Accreditation of continuing education has become a basic tool to guarantee the quality of contents and methodology of continuing health education in the National Health System (2) . Despite its voluntary character, accreditation of continuing health education in the world has remained constant, after a slight decrease (7%) following the financial crisis (42) . suppositions that they must meet for OLS regression, that is, homoscedasticity, residual normality, autocorrelation, and non-collinearity. In order not to modify the data, they were transformed in binomial distribution.

Conclusion
It can be concluded that the organizational, methodological, and resource-related characteristics that better predict the health professionals' satisfaction with continuing education are the following, in this order: activities with a face-to-face learning modality, clinical conferences with trained teaching professionals, low number of hours, education programmes that are concentrated in short period of time, reduced number of professionals, and activities' design based on quality criteria of accreditation models.
Lessons for the practice • The e-learning modality must be designed with learning objectives more adapted to the expectations of learners and of limiting the scope of the learning to knowledge rather than to the acquisition of skills.
• While educational supports have progressed considerably in recent years, the methodological designs and the pedagogical capacities of teachers and professionals who present clinical conferences have not followed the same pace.
• A reduced teacher-student ratio is recommended in order to facilitate learning and its applicability to employment positions.
It is recommended to base the design of the education on quality criteria of accreditation models.