Author:
Tetteh J. Zutah, MA, B.Sc., RN
Abstract
Curricula for nursing education in Ghana have evolved over the years; from a primordial form in the late 1870s through an intermediate form by 1928 to a standardized form by 1946. Ghana’s current nursing training curricula are a major revision of the previously existing ones. The curricular review established creditable precedence for addressing key challenges in the training and practice of nursing in Ghana, placing more emphasis on client-centred care and professional adaptability. Notwithstanding this milestone, implementation of the current curricula has key implications for training, practice and research. The purpose of this paper was to discuss these implications. A literature review was conducted by analysing the current curricula against previously existing ones, the WHO Global Standards for the Initial Education of Professional Nurses and Midwives, and related data retrieved from Google Scholar, Science Direct, PubMed, the N&MC of Ghana online repository, the WHO online database, and Ebscohost. It was found that the implementation process failed to initially consider the availability of tutors for new subjects introduced; and the revision failed to address some conflicts of standards between training and practice. Again, challenges relating to the baccalaureate programme were unaddressed. Stakeholder consultation, debate and research were suggested to address limitations discussed.
Keywords
nursing and midwifery; training curricula; curricular revision; nursing process; baccalaureate nursing
Correspondence:
Ankaful Leprosy General Hospital
P. O. Box DL 99
Cape Coast, Ghana
Tel: +233 (0) 263 933 920
Email: tjzpojoba@gmail.com
Approved Citation:
Zutah, J. T. (2017). A Review of Ghana’s Nursing Educational Curricula: Implications for Training, Practice and Research. Department of Nursing, ALGH: Cape Coast.
Introduction
Perhaps Virginia Henderson conceptualized nursing in the most pragmatic curricular context, stating that the essential function of the nurse is to “assist the individual, sick or well, in the performance of those activities contributing to health or its recovery, or to a peaceful death, that he would have performed unaided if he had the necessary strength, will or knowledge…” [1]. Henderson’s definition requires the professional nurse to be knowledgeable and skilled in the performance of core activities of daily living and to be able to assist the individual to perform those activities as the need arises. Acquiring the skill of nursing is therefore not a haphazard or random process but, in part, a systematic approach toward understanding and reproducing essential activities of daily living. An effective curriculum for nursing training therefore must essentially meet the skill and knowledge requirement of the student nurse [2]. This suggests that a good curriculum for nursing training must equip the student nurse to be able to give holistic or individualized care—assisting the helpless individual to perform essential activities of daily living. This involves dealing with cognitive, affective and, psychomotor problems [1, 3].
In Ghana, the training and practice of nursing had begun before the constitution of a standardized curriculum. Before the formal beginning of medicine in Ghana in 1878, nurses in the country were British expatriates who were sent down to primarily nurse other expatriates. When formal medical practice began, an attempt had to be made to train local complements as the expatriate nurses alone were too few to sustain the health system. The few locals who initially were courageous enough to enrol were trained by the British Sisters as nurse assistants and underwent in-service training in the hospitals. They were given fundamental lessons in Anatomy & Physiology, Hygiene, Surgical & Medical Nursing, Nutrition & Dietetics, and First Aid Techniques. These subjects formed the primordial curriculum for nursing education in Ghana. There were no general standards for the training programme in the country then. By 1928, a 3-year course was implemented to train these nurse assistants, still in the apprentice-based medium [4, 5]. Here, attention is drawn to the first curricular revision, giving birth to an intermediate curriculum to be run against a set timeline. Successful candidates were awarded the Director of Medical Service certificate and appointed as second-division nurses in the junior civil service [5].
When an increase in hospital patronage led to a commensurate shortage of nurses in the country by 1944, plans were rolled out to commence formal training of nurses in the country by 1945. To achieve this objective, the first standardized curriculum for nursing education was constituted and implemented. Successful candidates were awarded State Registered Nursing (SRN) certificates [6]. These were the first Ghanaian professional nurses trained in Ghana. The programme was regulated by the Nurses Board established in 1946 under the Nurse Ordinance and with assistance of the Nursing Council of England and Wales. Midwifery was a post-basic specialty done for 18 months after completion of the SRN programme before nurses were posted to practice. Those prospective applicants who could not meet the criteria for acceptance into the SRN programme were given mainly apprenticeship training at the hospitals and awarded Qualified Registered Nursing (QRN) certificates. By 1950, the standard of nursing training in Ghana was comparable to that in the UK [7, 4].
When Ghana gained independence in 1957, it became imperative to train more nurses due to socio-political changes. A commission was set up to review the educational system. For the first time, the idea of training nurses to meet health care needs specific to the country was proposed [6, 4]. This meant a review of the existing curricula and the introduction of new programmes. Until 1970, training was hospital based [4]. After successive coup d’états and government changes, the ‘Nurses and Midwives Council’ (NMC) of Ghana was commissioned under the LI 683 (1971) and NRCD 117 (1972). Following its establishment, the NMC built on existing training schedules for nursing in the country. When the QRN programme was replaced with a Comprehensive Nursing Care (CNC) programme, a shortage of auxiliary nurses was observed, leading to the rolling out of the Enrolled Nursing (EN) programme. In 1991, nursing training underwent another reform; and for the first time, the concept of competence-based nursing training was emphasized proposed [6, 4]. To make up for the practical deficit resulting from the shift from hospital-based training to college-based training, a one-year post-training internship was introduced, called ‘rotation’. But again, the curriculum was reviewed in 2000 and the SRN programme was changed to Registered General Nursing [4]. Part III of Act 857 of the Parliament of Ghana (Health Professions Regulatory Bodies Act) in 2013 re-established the ‘Nursing and Midwifery Council’ (N&MC) of Ghana as a statutory body with the core mandate of “securing in the public interest the highest standards of training and practice of nursing and midwifery” in the country [8].
The current nursing educational curricula, published in October 2015 and launched in February 2016 [9], are a major revision of the previously existing ones published about a decade ago [10]. The current edition emerged 6 years after the release of the ‘WHO Global Standards for the Initial Education of Professional Nurses and Midwives’; a policy document which requires all member countries to approach a certain minimum standard for the training and practice of nursing and midwifery across the world [11]. Notwithstanding the prospects of this revision, I argue that the current curricula are limited by key factors inherent to the revision and/or implementation process and contextual parameters. This paper sought to discuss these limitations and their implications for training, practice and research.
Design and Methods
A literature review was conducted by analysing the current curricula against the previously existing ones, the WHO Global Standards for the Initial Education of Professional Nurses and Midwives, and related data retrieved from Google Scholar, Science Direct, PubMed, the N&MC of Ghana online repository, the WHO online database, and Ebscohost. Key words used in literature search included nursing and midwifery training curricula; curricular revision; nursing process; and baccalaureate nursing. Only literature written in English were considered in this review. Thirty-five related articles which were identified were reviewed. Literature used in this review were published from 2004 to 2017. The literature review focused on nursing curricula and their implications for training, practice, and research. Except where indicated, specific references were made to the Registered General Nursing (RGN) curricula published by the Nursing and Midwifery Council of Ghana in July 2007 and October 2015.
Results and Discussions
In the current curriculum, Supply Chain Management; and Relationship Marketing Strategy & Entrepreneurship have been introduced, but as non-scoring courses; while French and Sign Language have also been added. Again, Communication & Study Skills, Computing and Perspectives of Nursing have been modified into Therapeutic Communication, Nursing Informatics and Professional Adjustment in Nursing respectively [12, 13]. These additions and modifications are replicated in the Registered Midwifery, Community Health and Mental Health Nursing programmes [13]. Again, there has been a major change in the final assessment (Licensing Examination) of student nurses. Previously, General Nursing candidates were assessed in 6 subjects: Medicine, Surgery, Obstetrics and Gynaecology, Paediatric Nursing, Public Health, and Psychiatric Nursing. There were both objective and subjective questions on all these courses. With the new curriculum, however, only Medicine and Surgery have been retained as major papers; while a ‘General Paper’ has replaced the 4 other papers that have been withdrawn. The General Paper requires candidates to attempt only objective questions that span ‘affiliation subjects’ that the candidate took during training. Similarly, licensing examination for the Registered Midwifery, Community and Mental Health Nursing programmes have been modified, likewise the Enrolled Nursing programme [13].
Ralph Tyler defined curriculum as all of the learning of students which is planned by and directed by the school to attain its educational goals [2]. Here, the goals of the school are shaped by the nursing needs of the patient. Now, because human needs are dynamic and are influenced by a myriad of factors, common of which are culture and environment, the goals of nursing training are bound to evolve with time. This is because those influencing factors are in themselves dynamic. It becomes necessary therefore for the nurse to be constantly aware of and responsive to changing needs of the individual which are brought about as society and human nature evolve. This reality or phenomenon presents a certain complexity to nursing, establishing basis and setting the stage for constant training-curricular reviews. To this extent, I argue that the curricular revision per se is justified. According to the N&MC, emphasis was laid on the community, physical, social, spiritual and ethical elements in nursing and midwifery in the development of the new curricula [12]; these elements inferably formed the practical and theoretical bases for the review. The old courses were selected to introduce the student nurse to both practical and theoretical experiences to prepare him or her for practice, and this has yielded creditable results. However, there were key limitations to the old curricula, which have been offset by the modifications and new courses introduced to place more emphasis on client-centred care and professional adaptability. These limitations have been discussed in the subsequent text.
Indications and Prospects for the Revision
While the old curricula sought to enhance the communication skills of nursing students by the Communication Skills course, there were apparent functional gaps which possibly were underscored by advances in the campaign for equity and access in healthcare. This limitation is addressed in the new curricula by the introduction of French, Sign Language and Therapeutic Communication. The introduction of Therapeutic Communication seeks to enrich clinical communication between the nurse and the client [12]. By this, student nurses are required to become increasingly aware of their own thought processes (metacognition) and be able to make logical judgment of those verbal and non-verbal cues of their clients [14]. To an extent, an aspect of hidden curriculum, which is evidenced by the learning of values, is given further credence. This enhances the learning of nursing values and ethics. Another limitation of the old curricula was that they merely prepared student nurses as clinicians and not leaders adequately capable of taking managerial roles. This had been documented as a worldwide challenge [11]. Although Management and Administration in Nursing has been a course in the old curricula, it is arguable that the impact of the course had not been felt over the years. The introduction of Supply Chain Management; and Relationship Marketing Strategy & Entrepreneurship promises to equip the student nurse to be able to develop problem-solving skills relative to management of healthcare logistics and supplies, and customer relations. The Entrepreneurship component aims at equipping the student nurse with innovative skills and some appreciable sense of self-reliance. This has become necessary, especially in recent times when employment of nurses has been challenged by socio-political and economic factors in Ghana. Again, with the modification of ‘Introduction to Computing’ (which introduced nursing students to basic computer knowledge) to Nursing Informatics (which is more function-based) nursing candidates should be able to develop the capacity to use modern electronic patient record keeping systems that are gradually replacing the paper record system. This course also aims at introducing the student nurse to a more efficient use of the internet and modern research tools [12, 10]. Finally, the revision of the licensing assessment should allow the student nurse to focus on his or her major subject areas, thereby enhancing mastery.
Limitations and Implications for Training, Practice and Research
Notwithstanding the creditable precedence established by the curricular revision for addressing key challenges in the training and practice of nursing in the country, I argue that there are important limitations to the revision, some of which are inherent to the review process. In the first place, the revision process failed to initially consider the availability of tutors for key subjects such as French and Sign Language, for example [9, 13]. With Supply Chain Management, Relationship Management & Strategy and Entrepreneurship, for example, there is the need for tutors with better understanding of the healthcare systems for effective tutoring to take place. A major implication of this revision is for stakeholders to establish and implement a tutor-training plan pursuant to the implementation of the revision. In searching for and reviewing documents relevant to this matter, no evidence of such plans was uncovered. Unless plans had already been instituted to address this issue, it should take some time for institutions to train tutors for these subject areas.
Also, the revision failed to address an existing confusion between the baccalaureate nursing (bachelor’s degree) and the trainee (diploma) programmes in Ghana. According to the Global Standards for the ‘Initial Education’ of Professional Nurses and Midwives:
Each country needs to have an adequate and sustainable source of health professionals, trained within the context of current and future issues in patient safety and quality of care, and trends in shortages of nurses and midwives and workforce migration. In implementing strategies to meet this goal, there is a need: a) to alter the skill mix of the future workforce to include a greater proportion of nurses and midwives who have been educated to degree level or higher, and b) to use definitions and competencies, such as those issued by international organizations representing nursing and/or midwifery [11].
The WHO explains ‘initial education’ as “the first programme of education required for a person to qualify as a professional nurse or midwife”. In the policy-document, the WHO suggests that the basic qualification for professional nursing should be a degree, which also suggests that professional nursing should preferably be taught at the baccalaureate level. In the same policy-document, the WHO mentions that:
The future of nursing and midwifery education lies in good preparation at the professional, first-degree level. This level of education is being successfully provided in many countries and research has demonstrated that a more highly educated nursing workforce not only improves patient safety and quality of care but saves lives [11].
The WHO recognizes the fact that despite the invaluable contribution of nurses to the workforce of many countries, nurses “are seldom involved in policy development for human resources for health or in high-level strategic decision-making.” It is suggested that the status and general level of education of nurses and midwives account for this observation. By this policy-directive, it is expected that graduates of the professional programme achieve, among other things, the following attributes: use of evidence in practice; critical and analytical thinking; cultural competence; ability to practise in the health-care systems of respective countries; the ability to manage resources; and leadership ability [11].
However, since the introduction of the baccalaureate nursing programmes relatively recently by some universities in Ghana, there have been challenges relating to its acceptance by the health care systems as well as opposition from the trainee (diploma awarding) institutions [15, 16, 17]. By March 2017, 108 institutions had been accredited to offer various nursing programmes in Ghana. Of these, only 15 are universities and offering nursing programmes (mainly Registered General Nursing and/or Midwifery) at the degree level [18]. As in many parts of the world, the notion of university education for nursing has been challenged [11]. In the UK, for example, the baccalaureate programme has been criticized on the basis of perceived failure to harness critical thinking skills [19]. In South Africa, no distinction has been placed between the degree and diploma programmes yet, in terms of course duration (4 years each), licensing and salary [20]. In the case of Ghana, challenges relating to salary payment by both state and private agencies may underpin the seeming reluctance to promote the baccalaureate programme. Again, the fact that candidates from both trainee and baccalaureate programmes take the same licensing examinations may have caused some stakeholders to perceive the standards as the same. Also, the anecdotal view that the baccalaureate programmes are rather theory-focussed (than practice-focussed) has fuelled a perception that diploma nurses perform better practically than degree nurses. This entire phenomenon seems to influence, in part, employment of baccalaureate nurses in Ghana. A common argument, for example, is: ‘Why should we employ a graduate nurse and pay more when we can employ someone else with diploma or certificate, pay less and still get the job done?’ [15, 17]. Contrary to the anecdotes above, higher education in nursing has been observed to improve nursing outcomes [21, 22, 11, 16]. While there may be need to separate the licensing assessment of baccalaureate nursing students, they may yet be a greater need to debate the place of baccalaureate nursing in the country.
Addressing the Conflicts of Standards
Revision of the existing curricula, appears to have been motivated in part by the launch of the WHO Global Standards for the Initial Education of Professional Nurses and Midwives. The policy-document by the WHO, published in 2009, required all member countries to aim at a certain minimum standard for the training and practice of nursing across the world, especially given the fact that the exchange of nursing personnel and health services across the globe continues to rise in recent years [23]. In the area of international graduate education, for example, prospective graduate nursing students may be required to attain certain minimum qualifications to enable them compete with others. According to WHO, nursing or midwifery schools should plan and design curricula to meet national and international education criteria, and professional and regulatory requirements for practice. Again, it states that nursing or midwifery schools should design curricula and deliver programmes that take into account national and international health-care policies. Perhaps the most essential point emphasized in the policy-directive by WHO is that:
Each country needs to have an adequate and sustainable source of health professionals, trained within the context of current and future issues in patient safety and quality of care, and trends in shortages of nurses and midwives and workforce migration…Individual schools, countries and/or regions are responsible for articulating and implementing specific strategies and appropriate success indicators according to their respective needs and situations [11].
The statement by the WHO above introduces or recognizes the idea of regional/sociocultural variations in nursing needs. To this extent, an idea of conflict of standards may be established. In principle, the use of established competencies as basis for building curricula or setting standards is essential for the development of nursing and midwifery. In practice, however, regional and/or sociocultural factors influence the application of these established competencies. Nurses are therefore inclined or compelled to do ‘what works’ in their respective contexts rather than follow standards that are not feasible or ‘rational’ due to the factors mentioned [24]. This again establishes the idea of ‘double standards’ in nursing training and practice.
In Ghana, modern nursing as a profession was formally established by the country’s colonial masters [4, 5]. As a result, the ideals taught in the Ghanaian nursing school have been foreign. And so the word ‘improvise’ has become a household name in the Ghanaian nursing profession since it becomes difficult to find or use some of the standards taught at school in the local settings. The confusion arises when candidates are trained to use tools or ideals that are not the day-to-day things seen in the local context. For a common example, a typical patient bed as taught in the Ghanaian nursing school must have at least 4 sheets (linens) and in some cases other supporting beddings or accessories such as ‘hot water bottles’ and ‘air-rings’. It is quite adorable to observe an ‘ideal’ patient bed-making at school, with all the sheets and bed accessories. But beyond the admiration is the question of contextual feasibility and applicability. For example, making ‘hot water bottles’ a requirement for bed-making may not be realistic locally. Of course, we cannot ignore the rationale for having it, which is to use it for patients presenting with hypothermia. Again, having both ‘top-sheet’ and counterpane for a typical patient bed seems questionable. Beside climate factors, the anecdote is that the typical Ghanaian hospital does not have ‘hot water bottles’, ‘airings’ or sufficient bed sheets for an ‘ideal’ patient bed-making. Would it therefore be sufficient to train professionals to rather use available alternatives? Is there a way local tools and methods can be improved, adopted and taught at schools? While this may require local debate and research, it remains important that the incongruence in training and practice be addressed. The goal of ‘cultural competence’ as an attribute expected from nursing education, according to the WHO [11], rests on addressing this issue. Perhaps a working example is seen with the ‘Kangaroo-mother-care’ technique taught to new mothers, especially those with preterm babies. This technique, which was adopted out of similar constraints, seems very applicable in context because the typical Ghanaian mother, who commonly dresses in cloth, can provide or use her own cloth [25].
The issue of conflicting standards is in part worsened by the fact that not many local professionals publish or contribute to the existing knowledge of nursing in the country. As a result, there seems to be inadequate documentation on the trends and needs of the profession in the country, thereby creating a knowledge gap [26]. In reviewing the recommended textbooks for the teaching and learning of Nutrition and Dietetics, for example, only two reference books, both by western publishers, were observed to have been cited in the curriculum: King, M. (Nutrition in Developing Countries) and Krause and Mahan (Food, Nutrition and Diet Therapy) [12]. The point here is that trends in nutrition vary regionally across the globe [27, 28]. Local research and publications in this area would logically be more useful in context.
It is important to recognize the implications of globalization to nursing education; but how much are the local health, economic and sociocultural systems changing relative to globalization? And how much are the changes, if any, affecting the country’s nursing needs. These are important questions that need to be addressed if nursing educational reforms in the country would be meaningful. Very importantly, how should nursing curricula draw the balance between standards and context? Is it sufficient to only train nurses based on the prevailing conditions or needs of the country? Finally, how do nursing educational institutions in Ghana ensure that international students in Ghanaian nursing schools attain the minimum standard of education required, as well as Ghanaian nurses with the prospect of pursuing further education abroad? These are questions that call for professional research, debate, and dialogue.
Perhaps an important approach to resolving the conflict of standards would be to compare nursing training in Ghana to medical training in the same country. There is a clear distinction between the MBChB (Medicine) and the BSc (Medical Assistantship/Community Medicine) programmes. The former programme, which is offered in Ghana’s main public universities, places much emphasis on emerging standards of training and practice. The latter, which originally started at the Rural Health Training School, Kintampo, trains students to more specifically manage regional or local medical problems, “especially in remote and under-served communities” [29]. This approach to medical education appears to have addressed the functional deficit or gap in the practice of medicine in the Ghanaian context. It is important to note that the Medical Assistantship/Community Medicine programme used to award ‘Advanced Diplomas’ to successful students. In response to growing standards, however, institutions running the programme are now awarding ‘Degrees’. Notwithstanding revisions to the curriculum or certification, the original goal or mandate of the Community Medicine programme has not been scrapped. It may become necessary therefore to have the nursing training colleges (Certificate and Diploma Awarding Institutions) focus on local or regional trends in the practice of nursing while the universities and university colleges focus on training ‘international-level’ nurses. In this case, we may have ‘Community Nursing’ and ‘General Nursing ‘programmes. Both programmes could then advance in line with their original goals or mandates.
The Nursing Process: Training Versus Context
The Nursing Process is a systematic problem-solving model used to identify, prevent and treat actual or potential health problems and promote wellness. It comprises five steps: Assessment, diagnosis, planning, implementation and evaluation [30, 31]. The model helps in planning good, clear, and effective nursing care [32]. An effective use of the nursing process is evidenced by nursing documentation. The nursing process, in principle, forms the framework for nursing practice. In the United States, for example, nursing students who are enrolled in the first year of nursing are trained to use this model [30]. Despite its importance, some studies have shown that the nursing process in practice is faced with numerous challenges [33, 34]. While some experts believe that the model in the present framework is not clear and is time-consuming, others believe that is difficult to use [34, 31, 35].
In Ghana, nursing students are introduced to the nursing process in the first year through the Basic Nursing course. In their final year, students learn to apply the nursing process individually in a 3-credit course known as Patient/Family-Centred Care Study. This course is expected to give the student the opportunity to apply the knowledge and skills acquired to offer comprehensive nursing care to a selected patient and family and to compile the care into a written document [12]. It is uncommon, however, to find adequate evidence of the use of the nursing process in the typical Ghanaian hospital [36]. It may therefore be necessary to consider contextual determinants of this observation. In the first place, the health care system has not necessarily enforced its use [37], and this may yet be a result of two factors: first, the perception of nursing as a profession only ancillary to medicine [38]; and second, doubt in the level of competence of nurses as suggested by the general level of nursing education [11]. If nurses are only perceived by the health system to be trained to take medical orders, then the attribute of professional autonomy which motivates the nurse to initiate, plan and implement relevant clinical interventions could be challenged. This ultimately leads to role confusion in practice or ‘reality shock’ as Kramer put it [39, 40]. Local debate and research as well as stakeholder consultation is needed to address this challenge.
Summary of Implications
Stakeholders must expedite plans to train tutors for newly introduced courses. The seeming existence of incongruence between training and practice in relation to standards and the nursing process must also be addressed through effective stakeholder consultation, local professional debate and research. This will help to identify and promote specific nursing ideals that may apply to the Ghanaian context. Finally, there is the need for stakeholder debate on the place of baccalaureate nursing in Ghana.
Conclusion
Curricula for nursing education in Ghana have evolved over the years, starting from a primordial form in the late 1870s through an intermediate form by 1928 and finally to a standardized form by 1946. The current curricula, as revised, promise to generally improve the standard of nursing training and practice in the country. Stakeholders must be commended for the effort made to review the old curricula. The revision has established precedence for addressing key challenges in the training and practice of nursing in the country. Notwithstanding, the revision process failed to initially consider the availability of tutors for new subjects introduced. Also, the revision failed to address some seeming conflicts of standards between training and practice of nursing in the country. Finally, challenges relating to the baccalaureate nursing programme were unaddressed.
Conflict of Interest
The author declares no competing interest for the publication of this paper.
Acknowledgments
The author acknowledges Alberta Afua Boateng for proofing and critiquing the write-up.
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