Continuing Professional Development: Perspectives of Kenyan Nurses and Midwives

Background: The purpose of this paper is to report the perceptions of continuous professional development by the nurses and midwives in a low resource country. These findings are part of a larger study on the experiences of nurses and midwives providing postpartum care in rural areas of Kenya. Besides being the main healthcare providers in rural areas, nurses in low resource countries have limited access to continuous professional development. Research design: This is a qualitative research guided by critical theory and Foucault’s concepts of power and knowledge. Focused ethnography provided the framework of data collection and analysis. 23 in-depth interviews were contacted, and thematic analysis was used for data analysis. Reflexive memos kept throughout the research process helped to ensure the trustworthiness of data. Findings: This paper will focus on the theme of continuing professional development (CPD) as a resource for a healthy work environment. While the knowledge of the nurses and midwives allowed them to provide care to the mothers and their infants adequately, personal and structural barriers prevented them from participating in continuing professional development. Discussion and Conclusion: A well-prepared nursing and midwifery workforce could have the capacity to transform the health outcomes of their clients through the application of evidence-based practices. Therefore, courses that are context-appropriate and meet the needs of different learners should be available to support the nurses’ and midwives’ professional growth. There is a need for more research on the nurses’ and midwives’ participation in CPD in Kenya, and the effect of CPD on specific health outcomes.


Background
Nurses and midwives account for about 50% of the healthcare workforce globally, and they often serve as primary caregivers in rural health facilities [1]. They play a significant role in the contribution of the sustainable Development Goals (SDGs), including preventing maternal and infant morbidities and mortalities and improving mothers' and their infants' health outcomes [2] [3]. Therefore, achieving health for all will depend on well-trained, educated, regulated, and supported nurses and midwives [1]. Most nurses undergo three to four years of basic nursing training that prepares them for a lifetime career. Hence, continuous knowledge update through further professional education is necessary to ensure their continued competency and improve nursing knowledge essential for the health system's functioning [4].
With the ever-changing technologies and emergence of new knowledge, nurses and midwives must engage in continuing professional development (CPD) to keep their clinical skills updated and promote safe and effective care [5]. CPD learning is not always possible for the nurses and midwives in rural areas of low resource countries. " [6]" stipulates that the nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. Therefore, CPD is an integral part of the nursing role in many nursing governing bodies. It facilitates team competence and promotes dialogue about the quality of knowledge and collaboration among the frontline healthcare providers [5].
Countries have different requirements for CPD. In Kenya, nurses and midwives complete at least 20 hours of (CPD) every year to maintain their registration every three years [7]. In the United Kingdom, the Nursing and Midwifery Board requires nurses and midwives to complete 35 hours of CPD every year. At least 20 hrs must have included participatory learning, for example attending a conference or participating in a workshop [8]. The College of Nurses of Ontario (CNO) has not set minimum hours. It stipulates that nurses are accountable for determining their own learning needs and maintaining and continually improving their competence by participating in the College of Nurses of Ontario's Quality Assurance (QA) Program. The QA program promotes reflection by nurses' and peers' feedback to identify their learning relevant to their practice. It includes performing a self-assessment, seeking peer input, developing a learning plan, implementing and evaluating the procedure's outcomes [9].
Besides the CPD requirement in Kenya, there is no clear evidence that the nurses and midwives have an enabling environment to accomplish these requirements.
This paper aims to report part of the findings of the study; experiences of nurses and midwives providing postpartum care in rural Kenya. One of the six themes in this study, Fostering a Healthy Work Environment, illuminated the continuous development of knowledge and skills as a facilitator in creating a positive work environment for the nurses and midwives. Regardless, several individual and structural factors prevented nurses from participating in CPD.

Theoretical Perspectives
The critical theory [10] and Foucault's concepts of power and Knowledge [11] guided this study. These theories illuminated how the complex contextual factors intersected to determine nurses and midwives' reality in rural Kenya. CT stance is that a comprehensive reality has been shaped by socio-economic, political, and cultural factors that are now considered real, with the facts constructed by those in power at history points [10]. Research that seeks to unearth the inequities and call for action could change these realities based on power and identity struggles [12]. Foucault understands power as a non-entity that produces reality with individuals being vessels of knowledge production [11]. Foucault's concepts of power and knowledge were relevant to this inquiry. Nurses and midwives could be in a position of power under their professional experience and underprivileged based on the history of the nursing profession's development [13].

Methodology
Focused ethnography (FE) informed the study design. FE is a more targeted form of ethnography where inquiry is conducted in a natural setting and seeks to acquire knowledge by focusing on particular elements in society, to address specific problems [14]. Unlike traditional ethnography that explores knowledge from the entire society, FE centers on the specific topic among a distinct group of persons, hence it is used to conduct research that aims to inform decision-making regarding a particular problem. For example, in this study, FE allowed a close examination of how several factors influenced nurses' and midwives' day-to-day work and potentially affected the health outcomes of mothers and infants in rural Kenya. The study emphasized the experiences of nurses and midwives as individual entities as well as located them within the health care professional group. With FE, the researchers can illuminate cultural phenomenon and health practices, and how they affect diverse cultures [14]. " [15]" explains that FE involves a limited number of participants, and research is problem-focused and context-specific, time-limited, with participants holding specific knowledge, and does not require prolonged observation in the field. Data collection and analysis occurred concurrently [18]. CT and Foucault's concept of power and knowledge, together with the investigator's experiences working in Kenya and North America, helped shape the meaning of the words during data analysis. Credibility, transferability, dependability, and confirmability were the aspects of trustworthiness used throughout the research process [19]. The investigator also engaged in reflexibility [20] as a conscious acknowledgement of the research process. Reflexivity was critical to avoid misrepresentation of the participants [21].

Findings
The sub-theme of "Continuing professional knowledge and skills development" There is a committee that coordinates the CME topics … we suggest to this committee the subjects that we wish discussed and they arrange a time for training … Sometimes, working in a health center without a doctor, there are difficult cases. When we have a difficult and rare case like cord prolapse, we discuss so that we gain more knowledge about it … it is better to know how to deal with a case so that when you are alone, you know what to do. (P020) Having the expertise of dealing with obstetric complications is particularly important when working in rural areas since most mothers, especially those who delivered at home would typically seek skilled healthcare only after complications to either the mother or the newborn. Nurses and midwives were empowered and confident when treating these disorders after they had received training on emergency obstetric complications.
Most of the referrals have life-threatening complications like postpartum hemorrhage. Some of us have been given some training in dealing with these cases. Therefore, when we receive them, we take the initiative to find out the cause of the hemorrhage … We can do more if we have the education you know. (P009) The nurse and midwife supervisors indicated that they participated in some training at least once a month in case management discussions with their colleagues, or by receiving updates from the reproductive health coordinators. The education activities occurred during the facility Progress Report Submission.
Each health facility is required to submit data on selected quality indicators such as the numbers of infants immunized, family planning, births, and maternal and infant mortalities, among others.
When we submit our monthly facility progress reports at the County office, we exchange ideas. For example, if someone had difficulty in dealing with a problem, we discuss amongst each other how to solve it. At these meetings, we also have CME to update on any new or revised policies and practices. We normally have CME when there is a new policy being rolled out. At least one nurse from each health center attends and they must give feedback to the rest of us when they return. We normally hold a meeting where they provide us with this feedback. Then they also provide us with training about the new policy (P005).
Inversely, while some participants stated that they received equitable opportunities for training, others expressed concerns with the irregularly distributed training opportunities amongst the nurses and midwives, and the lack of transparency in selecting staff who attended the training. Due to the per diem payment for attendance of some training sessions, it was likely that other healthcare Open Journal of Nursing professionals who did not require the training had priority to attend the activity regardless of its relevance to their job. Participants indicated that staff that legitimately needed the knowledge missed the opportunity to be trained, and as well, there was potential misuse of the already scarce resources.
From my experience, I don't find it to be an equal opportunity as such [ Immediately after delivery, we educate them on personal hygiene, if there is a tear or episiotomy, how to take care of it. How to watch for danger signs. We educate them on how to breastfeed the baby, how to latch, how many times to breastfeed the infant, how to do exclusive breastfeeding not including water unless it's only in medicine. We also give them information on family planning. We give them immunization information for the baby, and also what danger signs to watch for on herself and the baby and when to return to the hospital.
The lack of essential supplies, especially in the health centres, caused underutilization of their nurses and midwives' skills. As the following participant explains, We can insert here [the Intrauterine Device for family planning] -like all of us have gone for the training, but we don't have insertion sets. This sometimes creates those missed opportunities because some mothers can't travel to the referral hospital and so they end up being pregnant again sooner than they wanted to. (P011) The study found that there was no standardized procedure on how to offer continuing professional development to healthcare professionals in the County.
Additionally, the power imbalance created by the lack of a transparent process in the distribution of on-the-job training opportunities disempowered some nurses and midwives' environment. Nurses and midwives require empowerment to provide an empowered environment for their clients.

Discussion
Continuing professional development (CPD) is a lifelong learning process necessary for all nurses and midwives to keep up with the ever-changing health en-Open Journal of Nursing vironment by developing personal and professional skills and qualities needed throughout their careers. Being the largest group of healthcare providers, nurses, and midwives has a critical role in the overall quality of patient care, hence maintaining competence in their practice. A well-prepared nursing and midwifery workforce could have the capacity to transform their clients' health outcomes through the application of evidence-based practices [22].
All health professionals in Kenya are required to complete CPD [23]. Nurses and midwives in Kenya engage in both formal and non-formal learning. Although there were several modes of CPD sessions such as organized classroom events in the form of workshops or seminars, held either in the workplace or offsite, there were no transparent processes of ensuring equitable access to all nurses and midwives' learning opportunities. For example, shortages of staff inhibited nurses and midwives from participating in the training sessions. Some indicated that they were not able to attend the training because of family commitments.
Findings from this study indicated no standard training guidelines for nurses and midwives and a lack of clear structure in implementing new policies, processes, and procedures, which required standardized implementation of healthcare protocols and interventions. This lack of standardized healthcare protocols makes it challenging to evaluate the effects of learning and the gap between knowledge and practice for the nurses and midwives.
Similarly, in their study, [24] concluded that midwives in Kenya valued CPD.
Still, lack of a formalized structure for topic selection led to a limited or repetitive selection of topics, causing midwives to take courses that are not consistent with their practice area. They continued to say that midwives were not involved in the planning for their CPD activities, causing some not to participate due to time constraints and flexibility issues around family commitments [24]. The course completion demand to meet the professional's bodies' requirements infringes on nurses' and midwives' work and personal life outside of work, creating a sense of disempowerment. Hence, CPD platforms should allow nurses and midwives to choose the time, pace and place of the delivery of learning [25].
CPD courses are now available online for the nurses and midwives in Kenya to access through mobile applications. For example, Kenya's nursing council promoted free CPD courses in 2020 offered by the world continuing education alliance for nurses/midwives [26]. These online courses could not be timelier during the coronavirus disease (COVID-19) pandemic. However, besides internet access limitation, these courses are only available through some mobile devices limits to access to only those who have these particular mobile devices.
Further, it is not clear if these courses are context-specific. The learning activities that individuals engage in the workplace are context-specific influences that could benefit both individuals and organizational goals [25].
Other applications such as Safe Delivery are now available to provide support and information to healthcare providers on dealing with obstetric issues [27]. during the postpartum period contribute to high mortality and morbidity rates for mothers and their neonates. Hence access to best practices on postpartum management is necessary to curb these mortalities.
Failure to meet the health needs of women and infants in Kenya calls for an intersectionality lens, which critically looks at all intersecting elements to address issues related to the assessment, planning, development, and implementation of the CPD protocols. This study identified intersection elements that created barriers to CPD, such as lack of supervisor support, lack of time, limited access to computers and the internet, and limited financial resources were consistent with those identified by previous studies. Unavailability of dedicated time to learning due to staff shortages and increased workload contributed to the challenges to CPD participation in South Africa [28]. Even in developed countries such as Canada, nurses working in remote areas are hindered by time to attend educational events, since in most cases, they work alone [29]. Similarly, lack of appropriate and accessible professional education and lack of employer and supervisor support were among Australian nurses' barriers [30].
Given the high volumes of maternal and infant deaths in Kenya and other low-middle income countries, it is essential to meet the nurses, and midwives' learning needs working in rural areas. Although most of the nurses and midwives had received training on basic emergency obstetric and newborn care, they were unclear about their responsibilities in implementing healthcare policies, processes, and guidelines, such as the postpartum guidelines [17]. The lack of clarity to policies could cause extreme power imbalances between nurses and midwives and other healthcare providers [31]. Hence, there is the need to ensure CPD guidelines that include implementation structures and the monitoring and evaluation process. This process should also support sharing information with other healthcare professionals and visibility in the decision tables to enable policies that empower and capacity building of the nurses and midwives [32].

Limitations
This study had some limitations. First, the study examined nurses and midwives working in rural areas of one County in Kenya. Although generalizability is not a guiding principle in qualitative studies, findings from this study may not be generalizable, given the small participant sample. Second, the nurses and midwives participated in a national strike during the data collection period, which could have affected their participation and response to the interviews. Finally, the study did not include nurses who worked in the private sector and other healthcare professionals. Including them could have generated a more stimulated knowledge generation.

Conclusion
There is a requirement for more research on the nurses' and midwives' participation in CPD in Kenya, and the effect of CPD on specific health outcomes, including the CPD policy development that ensures context-appropriate courses.
That meets the needs of different learners to support the nurses' and midwives' self-reflection in prioritizing their learning needs. The CPD curriculum developers must consider other modes of administering the learning to ensure better uptake and practical knowledge and skills development for the nurses and midwives in rural areas of developing countries, such as Kenya. The intersecting barriers must be considered when developing CPD programs to ensure equitable and accessible learning opportunities for the nurses and midwives, regardless of the location of their primary work area.