What Keeps Ghana’s Nurses Competent? A sweeping review maps the barriers

Clinical competence is the invisible infrastructure of safe healthcare. Every correctly titrated drug dose, every early warning of patient deterioration, every calm response to an emergency on a crowded ward depends on a nurse whose skills are both current and reliable. Yet in Ghana, the systems that are supposed to build and sustain those skills have long been described as fragmented, underfunded, and unevenly applied. A new mixed-methods systematic review published in BMC Nursing brings that scattered evidence together for the first time, offering the most complete picture to date of how nurses in the country acquire clinical competency, why so many struggle to maintain it, and what actually works when health systems invest deliberately in their workforce.

The review, led by Donald Babamomba Amenah of the University of Maryland School of Nursing together with colleagues in Ghana, the United States, and the United Kingdom, followed the Joanna Briggs Institute methodology and the PRISMA reporting guidelines. The team searched four major bibliographic databases, MEDLINE, CINAHL, Scopus, and Embase, for empirical studies published between 2000 and 2026. From 379 articles initially retrieved, twelve studies met the inclusion criteria, encompassing 2,662 participants drawn from nurses, midwives, and nurse educators across Ghana. Because the underlying evidence combined quantitative measurements with qualitative accounts of lived experience, the authors used a convergent integrated approach, weaving numerical findings and narrative testimony into a single synthesis rather than reporting them in separate silos.

What distinguishes this review technically is its interpretive scaffolding. The authors organized their synthesis around two established frameworks from the learning sciences. The first is Patricia Benner’s Novice-to-Expert Model, which describes how clinical skill develops through five stages, from the rule-governed beginner who cannot yet prioritize among competing demands, to the expert practitioner who perceives situations holistically and acts intuitively. The second is Situated Learning Theory, which holds that professional competence is not simply transferred in classrooms but is constructed through participation in authentic communities of practice, where newcomers learn by working alongside experienced colleagues in real clinical environments. Together, these frameworks allowed the reviewers to classify each reported barrier or facilitator according to where it acts in the developmental trajectory of a nurse, and whether it shapes individual learning or the social and material conditions in which learning happens.

The barriers that emerged were strikingly consistent across the twelve studies, and the reviewers describe them as multilevel and system-driven rather than attributable to individual failings. At the level of education, inadequate structured clinical training was among the most frequently reported problems. Ghanaian nursing students and newly qualified nurses repeatedly encounter a theory-practice gap: the procedures and technologies described in lecture halls diverge from the realities of district hospitals and rural health centers, leaving graduates technically informed but practically unprepared. This gap is compounded by inconsistent competency assessment, meaning that there is no reliable, standardized mechanism for verifying that a nurse can actually perform the tasks their role demands, either at the point of qualification or at any stage afterward.

Workforce shortages emerged as a second dominant barrier, and their effect on competence is more mechanical than it might first appear. When wards are chronically understaffed, experienced nurses have no time to mentor juniors, and junior nurses have no time to reflect on or consolidate what they learn. Supervised practice, the mechanism through which Benner’s novice becomes an expert, simply cannot occur at the necessary intensity. Resource constraints compound the problem: when essential equipment, simulation materials, and training budgets are scarce, opportunities for deliberate practice and skills refreshment shrink accordingly. The review also identified limited managerial support as a recurring theme, with nurse managers often unable to release staff for training, advocate for development resources, or build the kind of workplace culture in which learning is expected and rewarded rather than treated as a luxury.

Against this backdrop of obstacles, the facilitators identified in the review point toward a coherent reform agenda. Structured mentorship and preceptorship programs were the most consistently reported enablers. In such arrangements, a designated experienced clinician takes formal responsibility for guiding a junior colleague through a defined period of supervised practice, providing feedback, modeling clinical reasoning, and gradually transferring responsibility as competence grows. The evidence suggests that when these programs are formalized, with clear roles, protected time, and defined learning objectives, rather than left to informal goodwill, they substantially improve the transition from student to competent practitioner.

Continuing professional development, or CPD, appeared as a second major facilitator, but the review’s findings here carry a caution. CPD in Ghana has historically been fragmented, with workshops and short courses delivered irregularly, unevenly across regions, and without a national framework tying them to competency outcomes. Where CPD was well organized and aligned with actual clinical needs, nurses reported gains in confidence and skill; where it was ad hoc, attendance alone became the measure of success, regardless of whether competence changed. Supportive leadership emerged as a third facilitator that cuts across the others, since managers who prioritize learning create the schedules, resources, and psychological safety that make mentorship and training possible in the first place.

The remaining facilitators identified, competency-based curricula in nursing schools and positive workplace learning environments, reinforce the review’s central analytical claim: competence is produced by a system, not by an individual’s effort alone. A competency-based curriculum defines what a graduate must be able to do, not merely what they should know, and assesses performance against those defined capabilities. A positive learning environment, meanwhile, transforms the ward itself into a classroom, where questions are welcomed, errors are treated as teaching opportunities, and experienced staff see developing juniors as part of their professional identity. Where these conditions coexisted, the studies synthesized in the review found nurses progressing more reliably along the novice-to-expert trajectory; where they were absent, even motivated nurses stagnated.

The policy implications set out by the authors are directed squarely at the Nursing and Midwifery Council of Ghana, the regulatory body that governs standards for the profession. The review calls for competency-based regulation to be strengthened through three institutional mechanisms: the formal institutionalization of structured mentorship and preceptorship programs across the health service, the introduction of systematic competency validation so that skills are verified periodically rather than assumed, and the creation of nationally coordinated continuing professional development that replaces the current patchwork with a coherent, quality-assured framework. The authors argue that these reforms are essential not only for Ghana but for other resource-constrained settings facing similar combinations of workforce shortage, funding limitation, and educational fragmentation, making the findings relevant far beyond West Africa.

The broader significance of this work lies in its reframing of what nursing competence actually is. The evidence assembled here shows that competence is neither a fixed attribute conferred by a diploma nor a personal virtue of diligent individuals, but a dynamic state that decays without reinforcement and grows only within supportive structures. In a global context of health worker shortages and rising demand for safe care, the Ghanaian experience offers a testable proposition: that modest, well-targeted investments in mentorship structures, competency assessment, and coordinated professional development may yield disproportionate returns in workforce capability. For a country striving to retain its nurses and deliver universal health coverage, the review provides something previously missing, a single, rigorous evidence base on which to build the systems that keep clinical skills alive.

Subject of Research: Barriers and facilitators to clinical competency acquisition and maintenance among nurses in Ghana

Article Title: Barriers and facilitators of clinical competency acquisition and maintenance among nurses in Ghana: a mixed methods systematic review

Article References: Amenah, D. B., Vog-Enga, E. W., Afaya, A., Fu, Y., Afaya, R. A., Daniels-Donkor, S. S., Suglow, E., Akwetea, B. L., & Kunaba, L. (2026). Barriers and facilitators of clinical competency acquisition and maintenance among nurses in Ghana: a mixed methods systematic review. BMC Nursing, 25(1), Article 904. https://doi.org/10.1186/s12912-026-05320-5

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05320-5

Keywords: clinical competence, nursing education, Ghana, continuing professional development, mentorship, preceptorship, nursing workforce, competency-based education, systematic review, mixed methods, Benner novice-to-expert model, situated learning