Structure, Process, and Outcomes of Liberian National Nursing and Midwifery Curricular Revisions.

Background: The Republic of Liberia has had major disruptions to the education of its health care cadres. Post Ebola, the Resilient and Responsive Health Systems (RRHS) initiative began a new era of capacity building with the support of PEPFAR and HRSA. Nursing and Midwifery serve as the largest healthcare cadres in Liberia. The national nursing and midwifery curricula were overdue for the regulated review and revisions. Methods: The Science of Improvement was used as the framework to accomplish this multilateral activity. The Institute for Healthcare Improvement's (IHI) stages of improvement included: 1) Forming the team, 2) Setting the aims, 3) Establishing measures, 4) Selecting measures, 5) Testing changes, 6) Implementing changes, and 7) Spreading changes. These stages served as the blueprint for the structures and processes put into place to accomplish this national activity. Findings: The RN, Bridging, and BScM curricula all had redundant content that did not reflect teaching pedagogy and health priorities in Liberia. Courses were eliminated or reconfigured and new courses were created. Development of Nursing and Midwifery Curricular Taskforces were not as successful as was hoped. Two large stakeholder meetings ensured that this was the curricula of the Liberian faculty, deans and directors, and clinical partners. Monitoring and evaluation tools have been adopted by the Liberian Board for Nursing and Midwifery to serve as another improvement to check that the new curricula are being implemented and to identify gaps that may require future cycles of change for continued quality and improvement. Conclusions: Developing trust among the multilateral partners was critical to the success of this activity. Networks have been expanded, and a proposed pilot with the Ghana Board of Nursing and Midwifery and the US academic partner will examine the feasibility of implementing electronic licensing examinations for nurses and midwives.

Normal Physiologic Birth Continuing Professional Development: From a National Health Priority to Expanded Capacity.

Background: The Republic of Liberia has experienced many barriers to maintaining the quality of its healthcare workforce. The Resilient and Responsive Health Systems (RRHS) Initiative supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has responded to Liberian identified health priorities. Liberia's maternal morbidity and mortality rates continue to rank among the highest in the world. Recent country regulations have put forth required continuing professional development (CPD) for all licensed healthcare workers for re-licensure. Methods: The Model for Improvement was the guiding framework for this CPD to improve midwifery and nursing competencies in assisting birthing women. Two novel activities were used in the CPD. We tested the formal CPD application and approval process as this is a recent regulatory body policy. We also included the use of simulation and its processes as a pedagogical method. Over a two-year period, we developed a two-day CPD module, using didactic training and clinical simulation, for Liberian midwives. We then piloted the module in Liberia, training a group of 21 participants, including midwives and nurses, including pre- and post-test surveys as well as observational evaluation of participant skills. Findings: There were no significant changes in knowledge acquisition noted in the post-test. Small tests of change were implemented during the program, supporting the stages of the Model of Improvement. Observation of skill acquisition was done; however, using a formal observation checklist, such as an Observed Structured Clinical Evaluation (OSCE), would add more robust findings. The CPD and follow-up activity highlighted the need for human and financial support to maintain the simulation kits and to create sustainability for future trainings. Videotaping the didactic and simulation two-day continuing professional development train-the-trainer workshop expands the sustainability beyond newly prepared trainers. Simultaneous with this CPD, the Liberian Board for Nursing and Midwifery (LBNM) worked with a partner to create a CPD portal. The CPD partners created modules from the videos and have uploaded these modules to the LBNM's new CPD portal. Conclusions: Using a quality improvement model as a framework for developing and implementing CPDs provides a clear structure and supports the dynamic interactions in learning and clinical care. It is too soon to determine measurable health outcomes resulting from this project. Anecdotal feedback from clinicians and leaders was not directly related to the content of the CPD; however, it does demonstrate an increased awareness of examining changes in practice to support expanded health outcomes. Further research to examine methods and processes to determine the quality and safety outcomes of CPD trainings is necessary.

The genetic basis of coordinated plasticity across functional units in a Lake Malawi cichlid mapping population.

Adaptive radiations are often stereotypical, as populations repeatedly specialize along conserved environmental axes. Phenotypic plasticity may be similarly stereotypical, as individuals respond to environmental cues. These parallel patterns of variation, which are often consistent across traits, have led researchers to propose that plasticity can facilitate predictable patterns of evolution along environmental gradients. This "flexible stem" model of evolution raises questions about the genetic nature of plasticity, including how complex is the genetic basis for plasticity? Is plasticity across traits mediated by many distinct loci, or few "global" regulators? To address these questions, we reared a hybrid cichlid mapping population on alternate diet regimes mimicking an important environmental axis. We show that plasticity across an array of ecologically relevant traits is generally morphologically integrated, such that traits respond in a coordinated manner, especially those with overlapping function. Our genetic data are more ambiguous. While our mapping experiment provides little evidence for global genetic regulators of plasticity, these data do contain a genetic signal for the integration of plasticity across traits. Overall, our data suggest a compromise between genetic modularity, whereby plasticity may evolve independently across traits, and low level but widespread genetic integration, establishing the potential for plasticity to experience coordinated evolution.

Plasticity and genetic basis of cichlid gill arch anatomy reveal novel roles for Hedgehog signaling.

Teleost gill arches are exquisitely evolved to maximize foraging efficiency, and include structures for the capture, filtering, and processing of prey. While both plasticity and a genetic basis for gill arch traits have been noted, the relative contributions of genetics and the environment in shaping these structures remains poorly understood. East African cichlids are particularly useful in this line of study due to their highly diverse and plastic feeding apparatus. Here we explore the gene-by-environmental effects on cichlid GRs by rearing pure bred species and their F3 hybrids in different foraging environments. We find that anatomical differences between species are dependent on the environment. The genetic architecture of these traits is also largely distinct between foraging environments. We did, however, note a few genomic "hotspots" where multiple traits map to a common region. One of these, for GR number across multiple arches, maps to the ptch1 locus, a key component of the Hedgehog (Hh) pathway that has previously been implicated in cichlid oral jaw shape and plasticity. Since Hh signalling has not previously been implicated in GR development, we explored functional roles for this pathway. Using a small molecule inhibitor in cichlids, as well as zebrafish transgenic systems, we demonstrate that Hh levels negatively regulate GR number, and are both necessary and sufficient to maintain plasticity in this trait. In all these data underscore the critical importance of the environment in determining the relationship between genotype and phenotype, and provide a molecular inroad to better understand the origins of variation in this important foraging-related trait.