Where Do We Go From Here: Using a Behaviorally Focused Applied Political Economy Analysis to Strengthen Continuing Professional Development in Ghana

"Nursing leaders/supervisors and care providers need a firm understanding of how CPD can and should be translated into quality care delivery, and the motivation to create an enabling environment that promotes role-specific CPD uptake and professional skill delivery for quality client care."

In Ghana, MOMENTUM Country and Global Leadership partnered with the country's Nursing and Midwifery Council (N&MC) to conduct a Behaviorally Focused Applied Political Economy Analysis (BF-APEA) process on continuing professional development (CPD) for nurses and midwives. BF-APEA is a highly participatory approach that ultimately results in behavioural profiles, with the goal of laying the groundwork for planning context-aware interventions that encourage behaviours that produce key outcomes. This report shares the findings of this process, as well as a co-created set of recommendations and solutions for the future of CPD in Ghana.

The BF-APEA process in Ghana took place from April to October 2022. To start the process, a kick-off meeting convened key stakeholders and decision-makers positioned throughout the CPD system. These individuals included leaders from 23 clinical training and service provision organisations from across the country as well as key policy-level actors from N&MC Ghana. These stakeholders collaboratively worked to complete a series of key participatory steps in the BF-APEA process: articulate a goal, describe impediments to the goal, identify behaviours critical to resolving those impediments, and conduct action planning through a series of meetings and workshops. Along the way, information is deliberately evaluated and validated using available secondary literature. To validate insights generated, BF-APEA team leads use targeted primary data collection methods - primarily key informant interviews (KIIs) and focus group discussions (FGDs) - to fill gaps in knowledge and leverage stakeholders' collective knowledge of the challenges and motivations faced in practicing key behaviours.

This process revealed that the goal of CPD in Ghana is to equip all cadres of practitioners at all levels of care to demonstrate relevant, international standards-based, culturally sensitive competencies and to utilise reflective practice to improve health outcomes. To achieve this goal, certain key behaviours must be systematically practiced (e.g., course content creators ensure that the curriculum is skills based and culturally relevant, and they streamline the interface and instructions). BF-APEA highlighted that various foundational factors affect the practice of these behaviours, including: accessibility, perception of quality, and relevance; social and institutional factors such as power dynamics, social and institutional support, and gender; the rules of the game, such as laws, policies, norms, and economic incentive or market influences; and historical experience and the influence of current events.

For example, discussions with supervisors depicted a cadre of providers who were deeply committed to and interested in the quality of services but who also struggled with significant pressure to make the most out of very limited resources with little support. Existing in-facility professional development units are understaffed and mostly focused on supporting new graduates to integrate into a facility, rather than supporting ongoing or lifelong learning. District-level policymakers and other system actors who could support the CPD system do not engage within the facility at that level, and often CPD moves to the bottom of the priority list for these supervisors.

While most participants felt that the BF-APEA process did not identify much that surprised them, they did note that the presentation of factors affecting practice of behaviours was new and that they had never used those factors to structure thinking about solutions. Most stakeholders were enthusiastic about this process and felt encouraged that the factors were now well documented and described and could not be ignored. Accordingly, once the research findings were validated, the stakeholders began to use them to identify pathways to change.

Specifically, the team crafted the following list of recommendations for the N&MC and Ghana Health Service:

• Create a transparent and clear system for rotational release of staff for CPD.
• Develop CPD courses that encompass care bundles unique to specific professional cadres, particularly those related to nursing and midwifery and current placements.
• Develop and implement a training needs assessment as part of staff performance appraisals.
• Formally coordinate CPD within facilities across wards, including identifying needs and topics, a schedule of dates and times/locations, and housing of offline videos for areas with low connectivity.
• Standardise protocols and identify opportunities for sponsorship for providers to attend courses they otherwise could not afford.
• Create a dedicated CPD strategy for reaching remotely placed/rural care providers.
• Establish specific tracks for different cadres of providers, including both optional and mandatory courses (e.g., for nursing leaders, mandatory courses should focus on critical nonclinical skills, such as self-care/mental health, leadership, ethics, and technology).
• Revive or establish fixed or mobile learning or skills labs within each ward.
• Create supply and resource lists for each course and match the lists to available supplies in facilities prior to course attendance.
• Include a local CPD needs assessment in annual planning between facilities and district health officers.
• Expand breadth of teaching methodologies in all courses, including discussion, role plays, and practicums.
• Establish a formal policy for sharing new learning and ongoing challenges within facilities or wards (seminars, lunches, grand rounds type).
• Expand types of providers accredited to offer CPD, including more private providers.

MOMENTUM Country and Global Leadership is part of a suite of awards funded by the United States Agency for International Development (USAID) to holistically improve voluntary family planning and maternal and child health in partner countries around the world.