The intellectual capital supporting nurse practice in a post-emergency state: A case study.

AIM: To explore the resources supporting current nurse practice in the post-emergency country of Liberia, using the nursing intellectual capital framework, as nurses work to meet the targets set by Government of Liberia's Essential Package of Health Services. DESIGN: Case study. METHODS: Data were collected in Liberia February-June 2019. Direct observation, semi-structured interviews and photographs were used to investigate how nurse practice is supported. Field notes, transcripts and photographs were coded using both directed and conventional content analysis. Reports were then generated by code to triangulate the data. RESULTS: Thirty-seven nurses at 12 health facilities participated. The intellectual capital supporting inpatient and outpatient nurse practice differs in important ways. Inpatient nurse practice is more likely to be supported by facility-based protocols and trainings, whereas outpatient nurse practice is more likely to be supported by external protocols and trainings, often developed by the Liberian government or non-governmental organizations. This can lead to uneven provision of inpatient protocols and trainings, often favouring private facilities. Similarly, inpatient nurses rely primarily on other nurses at their facilities for clinical support while outpatient nurses often have external professional relationships that provided them with clinical guidance. CONCLUSION: Much has been accomplished to enable outpatient nurses to provide the primary- and secondary-care target services in the Essential Package of Health Services. However, as the Liberian government and its partners continue to work towards providing certain tertiary care services, developing analogous protocols, trainings and clinical mentorship networks for inpatient nurses will likely be fruitful, and will decrease the burden on individual facilities. IMPACT: Nurses are often expected to meet new service provision targets in post-emergency states. Further research into how best to support nurses as they work to meet those targets has the potential to strengthen health systems.

Gaps and Opportunities in HIV Service Delivery in High Volume HIV Care Centers in Liberia: Lessons From the Field.

Background: Human Immunodeficiency Virus (HIV) infection continues to have a profound humanitarian and public health impact in western and central Africa, a region that risks being left behind in the global response to ending the AIDS epidemic. In Liberia, where the health system is being rebuilt following protracted civil wars and an Ebola virus disease outbreak, the Resilient and Responsive Health System (RRHS) is assisting with quality HIV services delivery through support from PEPFAR and HRSA but gaps remain across the cascade of care from diagnosis to viral load suppression. Objective: To highlight gaps in HIV service delivery in Liberia, identify opportunities and offer recommendations for improving the quality of service delivery. Methods: A narrative review of relevant literature was conducted following a search of all local and online databases known to the authors. Findings: Antiretroviral therapy (ART) has transformed the HIV response in Liberia by averting deaths, improving quality of life, and preventing new HIV infections but critical gaps remain. These include weak HIV prevention and testing strategies; suboptimal ART initiation and retention in care; low viral load testing volumes, commodity supply chain disruptions and a HIV workforce built on non-physician healthcare workers. In the context of the prevailing socioeconomic, heath system and programmatic challenges, these will impact achievement of the UNAIDS targets of 95-95-95 by 2030 and ending the epidemic. Conclusion: Combination prevention approaches are necessary to reach the most at risk populations, while a robust health workforce operating through facilities and communities will be needed to reach people with undiagnosed HIV earlier to provide efficient and effective services to ensure that people know their HIV status, receive and sustain ART to achieve viral suppression to maintain a long and healthy life within the framework of overall health system strengthening, achieving universal health coverage and the sustainable development goal.

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.

Facing COVID-19 in Liberia: Adaptations of the Resilient and Responsive Health Systems Initiative.

The 5-year Resilient and Responsive Health Systems (RRHS)-Liberia Initiative, funded by PEPFAR via HRSA, launched in 2017 and was designed to support the implementation of Liberia's National Health Workforce Program as a means to improving HIV-related health outcomes. The COVID-19 pandemic, arrived in Liberia just five years after Ebola and during RRHS-Liberia's fourth year, impacted educational programs and threatened the project's continued work. This paper presents the challenges that the COVID-19 pandemic posed to the RRHS partners, as well as adaptations they made to maintain progress towards project goals: 1) contributing to Liberia's 95-95-95 HIV targets via direct service delivery, and 2) building a resilient and responsive health workforce in Liberia via instruction and training. Direct health service impacts included decreased patient volumes and understaffing; adaptations included development of and trainings on safety protocols, provision of telehealth services, and community health worker involvement. Instruction and training impacts included suspension of in-person teaching and learning; adaptations included utilization of multiple online learning and virtual conferencing tools, and increasing clinical didactics in lieu of bedside mentorship. The RRHS team recommends that these adaptations be continued with significant investment in technology, IT support, and training, as well as close coordination among partner institutions. Ultimately, the RRHS Liberia consortium and its partners made significant strides in response to ensuring ongoing education during the pandemic, an experience that will inform continued service delivery, teaching, and learning in Liberia.

How clinicians manage routinely low supplies of personal protective equipment.

BACKGROUND: Recommended personal protective equipment (PPE) is routinely limited or unavailable in low-income countries, but there is limited research as to how clinicians adapt to that scarcity, despite the implications for patients and workers. METHODS: This is a qualitative secondary analysis of case study data collected in Liberia in 2019. Data from the parent study were included in this analysis if it addressed availability and use of PPE in the clinical setting. Conventional content analysis was used on data including: field notes documenting nurse practice, semi-structured interview transcripts, and photographs. RESULTS: Data from the majority of participants (32/37) and all facilities (12/12) in the parent studies were included. Eighty-three percent of facilities reported limited PPE. Five management strategies for coping with limited PPE supplies were observed, reported, or both: rationing PPE, self-purchasing PPE, asking patients to purchase PPE, substituting PPE, and working without PPE. Approaches to rationing PPE included using PPE only for symptomatic patients or not performing physical exams. Substitutions for PPE were based on supply availability. CONCLUSIONS: Strategies developed by clinicians to manage low PPE likely have negative consequences for both workers and patients; further research into the topic is important, as is better PPE provision in low-income countries.

Infection Prevention and Control in Liberia 5 Years After Ebola: A Case Study.

BACKGROUND: Effective management of health emergencies is an important strategy to improve health worldwide. One way to manage health emergencies is to build and sustain national capacities. The Ebola epidemic of 2014 to 2015 resulted in greater infection prevention and control (IPC) capacity in Liberia, but few studies have investigated if and how that capacity was sustained. The purpose of this study was to examine the maintenance of IPC capacity in Liberia after Ebola. METHODS: For this case study, data were collected via direct observation of nurse practice, semistructured interviews, and document collection. Data were collected in two counties in Liberia. Data were analyzed using directed content and general thematic analysis using codes generated from the safety capital theoretical framework, which describes an organization's intangible occupational health resources. FINDINGS: Thirty-seven nurses from 12 facilities participated. Ebola was a seminal event in the development of safety capital in Liberia, particularly regarding nurse knowledge of IPC and facilities' investments in safety. The safety capital developed during Ebola is still being applied at the individual and organizational levels. Tangible resources, including personal protective equipment, however, have been depleted. CONCLUSIONS/APPLICATION TO PRACTICE: IPC capacity in Liberia had been sustained since Ebola but was threatened by under-investments in physical resources. Donor countries should prioritize sustained support, both financial and technical, in partnership with Liberian leaders. Occupational health nurses participating in disaster response should advocate for long-term investment by donor countries in personal protective equipment, access to water, and clinician training.

Design and outcomes of a nurse practitioner preceptor development program.

ABSTRACT: Nurse practitioners (NPs) are educated to provide high-quality patient- and family-centered care to underserved, culturally diverse, medically complex populations. Nurse practitioner faculty plan curricular activities that challenge NP students to critically assess individuals and populations with the goal of preparing NP students to be "practice-ready" upon graduation. Nurse practitioner clinical training occurs in practice settings with NP preceptors, with specific areas of clinical expertise. However, there is a lack of NP clinical preceptors educationally prepared to clinically teach and evaluate NP students. This article presents the design, implementation, evaluation, and outcomes from a 3-year grant funded by the United States Human Resources and Administration Services that featured a web-based Primary Care Nurse Practitioner Preceptor Development Program. Ninety percent of NPs who precepted NP students completed all web-based learning modules. Preceptors with educational preparation via online modules to guide NP student learning in clinical settings are a critical resource for faculty to prepare NP students to be practice-ready upon graduation. This web-based learning platform for online NP preceptor education may be a successful approach for expanding and improving the NP preceptor pool nationwide.

Nurse Educators as Agents of Change in the SARS-CoV-2 Pandemic.

The coronavirus pandemic caused a rapid and seismic shift in the provision of nursing education. In this commentary, I provide examples of how faculty and students at my university made the shift and what we have learned from the experience thus far.

Traditional and Nontraditional Collaborations to Improve Population Health Using Geospatial Information SystemMaps: Analysis of the Opioid Crisis.

INTRODUCTION: The study aims were to analyze interprofessional practice collaborations among traditional and nontraditional health care providers and to educate nurse practitioner preceptors and students on population health, specifically, implementation of geospatial information system (GIS) maps and the correlation with the opioid crisis. METHODS: A descriptive analysis was used to examine New York State data on the opioid crisis in comparison to outcome data from GIS maps of opioid use in two boroughs in New York City. Web-based modules were designed for analysis of GIS maps of opioid use near practice settings. RESULTS: New York State data provided context for local opioiduse, while GIS maps identified specific areas of the New York City boroughs that were most affected by the opioid epidemic. DISCUSSION: The importance of local GIS maps is that the information is available in real-time, and thus interventions can be designed, evaluated, and changed quickly to meet the immediate needs of the community.

The meaning of "capacity building" for the nurse workforce in sub-Saharan Africa: An integrative review.

BACKGROUND: "Capacity building" is an international development strategy which receives billions of dollars of investment annually and is utilized by major development agencies globally. However, there is a lack of consensus around what "capacity building", or even "capacity" itself, means. Nurses are the frequent target of capacity building programming in sub-Saharan Africa as they provide the majority of healthcare in that region. OBJECTIVES: This study explored how "capacity" was conceptualized and operationalized by capacity building practitioners working in sub-Saharan Africa to develop its nursing workforce, and to assess Grindle and Hilderbrand's (1995) "Dimensions of Capacity" model was for fit with "capacity's" definition in the field. DESIGN: An integrative review of the literature using systematic search criteria. DATA SOURCES SEARCHED INCLUDED: PubMed, the Cumulative Index for Nursing and Allied Health Literature Plus, the Excerpt Medica Database, and Web of Science. REVIEW METHODS: This review utilized conventional content analysis to assess how capacity building practitioners working in sub-Saharan Africa utilize the term "capacity" in the nursing context. Content analysis was conducted separately for how capacity building practitioners described "capacity" versus how their programs operationalized it. Identified themes were then assessed for fit with Grindle and Hilderbrand's (1995) "Dimensions of Capacity" model. RESULTS: Analysis showed primary themes for conceptualization of capacity building of nurses by practitioners included: human resources for health, particularly pre- and post- nursing licensure training, and human (nursing) resource retention. Other themes included: management, health expenditure, and physical resources. There are several commonly used metrics for human resources for health, and a few for health expenditures, but none for management or physical resources. Overlapping themes of operationalization include: number of healthcare workers, post-licensure training, and physical resources. The Grindle and Hilderbrand (1995) model was a strong fit with how capacity is defined by practitioners working on nursing workforce issues in sub-Saharan Africa. CONCLUSIONS: This review indicates there is significant informal consensus on the definition of "capacity" and that the Grindle and Hilderbrand (1995) framework is a good representation of that consensus. This framework could be utilized by capacity building practitioners and researchers as those groups plan, execute, and evaluate nursing capacity building programming.

Continuous professional development of Liberia's midwifery workforce-A coordinated multi-stakeholder approach.

BACKGROUND: Maternal and newborn mortality remains high in Liberia. There is a severe rural-urban gap in accessibility to health care services. A competent midwifery workforce is able to meet the needs of mothers and newborns. Evidence shows that competence can be assured through initial education along with continuous professional development (CPD). In the past, CPD was not regulated and coordinated in Liberia which is cpommon in the African region. AIM: To Support a competent regulated midwifery workforce through continuous professional development. METHODOLOGY: A new CPD model was developed by the Liberian Board for Nursing and Midwifery. With its establishment, all midwives and nurses are required to undertake CPD programmes consisting of certified training and mentoring in order to renew their practicing license. The new model is being piloted in one county in which regular mentoring visits that include skills training are being conducted combined with the use of mobile learning applications addressing maternity health issues. Quality control of the CPD pilot is assured by the Liberian Board for Nursing and Midwifery. The mentoring visits are conducted on a clinical level but are coordinated on the national and county level. SUCCESSES AND SUSTAINABILITY: CPD using mobile learning on smartphones and regular mentoring visits not only improved knowledge and skills of midwives and nurses but also provided a solution to enhance accessibility in rural areas through improved communication and transportation, as well as improved career development of health personnel working in remote areas. Mentors were trained on a national, county, and health facility level in the pilot county with mentoring visits conducted regularly. CONCLUSION: The CPD programme of the Liberian Board for Nursing and Midwifery, currently in pilot-testing by various partners, aims to highlight the positive impact of the coordinating role of both the regulatory body and health authorities. Using regular process and programme reviews to improve capacity, knowledge, and skills of health professionals.

Macrocognition in the Healthcare Built Environment (mHCBE): A Focused Ethnographic Study of "Neighborhoods" in a Pediatric Intensive Care Unit.

OBJECTIVES: The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the healthcare built environment (HCBE) using those constructs to explicate influences on macrocognition. BACKGROUND: In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple healthcare settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, "macrocognition in the healthcare built environment" (mHCBE) addresses this relationship. METHOD: A focused ethnographic study was conducted including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data. RESULTS: Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs). CONCLUSIONS: Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how use of the framework of Macrocognition in the HCBE can improve design and support adaptation of interprofessional team practices, maximizing macrocognitive interaction opportunities for patient, family, and team safety and quality.

Working hard: women's self-care practices in Ghana.

Women's health care providers have noted an increased infant mortality rate among Ghanaian immigrants. We conducted focus groups with 17 women in Ghana. We asked them how they maintained their health both before and during pregnancy. When discussing their health, women repeatedly described the conditions or context of their daily lives and the traditional practices that they used to stay healthy. Knowledge of women's lives, the health care system that they previously used, and their cultural practices can be utilized by health care providers to more fully assess their patients and design more culturally appropriate care for this group of women.

The research advisory committee: an effective forum for developing a research dynamic environment.

This article describes the role of a committee in the Graduate School of Nursing at the University of Massachusetts, Worcester, that is referred to as the research advisory committee. It was developed to sustain the research mission, to facilitate faculty scholarship, and to provide a venue for presubmission grant review (hence called mock review) in a graduate school of nursing that is not considered "research intensive." We present its historical framework, the development of a mock review process, faculty accomplishments thus far, and our plans for the future. It is hoped that our experiences of building and supporting faculty research efforts in a research dynamic environment may provide guidance for others working in similar institutions.