Nurse Education in Practice 25 (2017) 66e73

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Building midwifery educator capacity using international

partnerships: Findings from a qualitative study
Florence West*, Angela Dawson, Caroline S.E. Homer
Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Midwifery educators play a critical role in strengthening the midwifery workforce globally, including in
Received 16 December 2016 low and lower-middle income countries (LMIC) to ensure that midwives are adequately prepared to
Received in revised form deliver quality midwifery care. The most effective approach to building midwifery educator capacity is
29 March 2017
not always clear. The aim of this study was to determine how one capacity building approach in Papua
Accepted 7 May 2017
New Guinea (PNG) used international partnerships to improve teaching and learning. A qualitative
exploratory case study design was used to explore the perspectives of 26 midwifery educators working in
Keywords:
midwifery education institutions in PNG. Seven themes were identified which provide insights into the
Midwifery
Education
factors that enable and constrain midwifery educator capacity building. The study provides insights into
International strategies which may aid institutions and individuals better plan and implement international midwifery
Partnership partnerships to strengthen context-specific knowledge and skills in teaching. Further research is
necessary to assess how these findings can be transferred to other contexts.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction
High level evidence demonstrates that when the quality and
quantity of the midwifery workforce is sufficient, maternal and
newborn lives are saved (Frenk et al., 2010; Fullerton et al., 2011;
Homer et al., 2014; Renfrew et al., 2014; ten Hoope-Bender et al.,
2014; UNFPA et al., 2014). The International Confederation of
Midwives has developed global standards to guide the develop-
ment of a midwifery workforce to provide high-quality, evidence-
based care for women. This involves strengthening what is known
as the three pillars of midwifery which encompass professional
association, regulation and education (International Confederation
of Midwives, 2015; UNFPA et al., 2014; World Health Organization,
2014). Education, as one of these pillars, is the focus of this paper.
A learning environment that provides strong midwifery lead-
ership, effective governance and adequate resourcing of teaching,
clinical simulation and practice can produce quality midwifery
graduates (Dawson et al., 2015; Frenk et al., 2010). However, in
many low and middle income countries (LMIC), midwifery educa-
tion institutions face many challenges to deliver quality teaching
* Corresponding author.
E-mail addresses: florencewest74@gmail.com (F. West), Angela.dawson@uts.
edu.au (A. Dawson), Caroline.homer@uts.edu.au (C.S.E. Homer).
and learning (Frenk et al., 2010). Issues that prevent midwifery
educators from maintaining their competency in teaching and
clinical practice include staffing shortages that limit the time ed-
ucators have for professional development (Fullerton et al., 2011).
There are also a limited number of suitable professional develop-
ment programs for midwives in rural areas (Dawson et al., 2015;
Frenk et al., 2010; Lemay et al., 2012), inadequate access to the
internet and poor computer literacy both of which can lead to the
use of outdated or incomplete reference materials for teaching
(Brodie, 2013).
Improving the capacity of midwifery educators is necessary to
strengthen midwifery education and support the development of a
quality midwifery workforce. Study abroad, the provision of
externally-facilitated online training modules, regional collabora-
tion and international consultants are some approaches that have
been employed with varying levels of success to build educator
capacity (Lasker, 2015; Forss and Maclean, 2007; West et al., 2015).
The literature shows that international partnerships to
strengthen midwifery have been facilitated by education in-
stitutions, volunteers, faith based organisations, non-government
and other international agencies who often work collaboratively
with local partners to implement local government health policy
and planning (Liberato et al., 2011; Yamey, 2012). Little is known
about the key features of international partnerships that enable
individuals and organisations to most effectively strengthen

http://dx.doi.org/10.1016/j.nepr.2017.05.003
1471-5953/© 2017 Elsevier Ltd. All rights reserved.
 F. West et al. / Nurse Education in Practice 25 (2017) 66e73
midwifery teaching in education institutions in LMIC.
One international partnership to build midwifery capacity was
the Papua New Guinea (PNG) Maternal and Child Health Initiative
(MCHI). The aim of this paper is to explore how the approach taken
by the MCHI enabled international and national midwifery edu-
cators, working in a cross-cultural partnership, to strengthen
midwifery teaching and learning in PNG.
1.1. The PNG Maternal and Child Health Initiative
PNG is a low-income country in the South Pacific (World Bank,
2014) with approximately 250,000 births a year (World Health
Organization, 2015). The majority of the population reside in
geographically isolated rural areas which contributes to the low
rate of skilled attendance at birth of 44% and high maternal mor-
tality ratio (MMR), estimated to be around 773 maternal deaths per
100, 000 live births (Papua New Guinea National Government,
2009; World Bank, 2011; World Health Organization, 2015). The
PNG government developed strategies to address this high MMR,
which included increasing the number and quality of midwives. A
key component of the strategy was focused on strengthening
midwifery education (UNFPA et al., 2014) which is also the focus of
the MCHI.
The specific objectives of the PNG MCHI were to improve the
standard of midwifery clinical teaching and practice in the four
teaching sites (that expanded to five in mid-2015); and improve the
quality of obstetrical care in two regions through the provision of
clinical mentoring, supervision and teaching (World Health
Organization Collaborating Centre for Nursing, Midwifery and
Health Development, 2014).
An Australian university supported the PNG MCHI over a four
year period. This support included: the recruitment of international
midwives and obstetricians to work alongside midwifery educators
in the midwifery teaching programs, facilitating three national
education workshops a year to build the capacity of national edu-
cators, supporting the midwifery regulatory body to improve sys-
tems and processes, conducting monitoring and evaluation of the
MCHI and making changes where required, and providing ongoing
support to the international and national educators through regular
teleconferences, face-to-face mentoring and clinical supervision.
International midwifery educators (known as Clinical Midwifery
Facilitators or CMFs) and the two obstetricians were provided with
an orientation program before arriving in PNG. The program pro-
vided a background on the state of maternal and child health in
PNG, cultural awareness training, and an opportunity to build re-
lationships with other international educators and the coordinating
team at UTS.
At the time this study was conducted (March 2015), Phase I of
the PNG MCHI was ongoing.
During Phase I (2012e2013), eight CMFs worked as midwifery
educators in partnership with PNG midwifery educators and cli-
nicians in the four education institutions and clinical practicum
sites. Education institutions were governed and administered
either by the PNG government or private religious-affiliated orga-
nisations. The CMF provided pedagogical and clinical updates and
mentoring to the national educators. The national educators pro-
vided valuable local context experience, skills, and cultural insights
to the international educators. The midwifery education workshops
provided opportunities for participation in simulated teaching and
learning in a collaborative and multidisciplinary environment. The
provision of teaching resources included clinical simulation
equipment and mannequins, textbooks, hard copies of World
Health Organization (WHO) midwifery education modules and
other audio-visual resources. Teleconference, email and telephone
support was provided to the international educators by a senior
67
international midwifery mentor who had experience working in
PNG.
The aim of this study therefore was to determine how this
approach contributed to strengthening midwifery education in this
low income context, in particular factors that enables or con-
strained these processes.
2. Methods
2.1. Design
A qualitative exploratory case study design was used. Qualitative
case study research enables an in-depth understanding of phe-
nomena in a real-life context when the boundaries between phe-
nomenon and context are not always clear (Baxter and Jack, 2008;
Creswell, 2013; Harder, 2010; Yin, 2012). In addition, a qualitative
inquiry using a case study approach enabled an exploration of the
perspectives of the international and national educators in the
MCHI in order to ensure that all voices were represented in the
study (Yin, 2009).
Case studies have been used extensively in social sciences, ed-
ucation and health (Yamey, 2012; Yin, 2009) and this method has
contributed to knowledge of individual, social and organisational
phenomena (Brideson et al., 2012; Fraser et al., 2013). A theoretical
framework of behaviour change, called the Theory of Planned
Behaviour (TPB) was used to inform the data collection and analysis
in order to identify the factors that contributed to and influenced
capacity building.
Capacity building is primarily concerned with enabling behav-
iour change to improve outcomes (Labonte and Laverack, 2001;
Lavender et al., 2009; Liberato et al., 2011; West et al., 2015). In
the context of this study, behaviour change is related to the inter-
national expatriate's adaptive behaviour to the environment and
culture and the national host's reciprocal acceptance and utilization
of the methods of teaching and facilitation of learning. The TPB is
concerned with the factors which influence an individual's inten-
tion to perform (or not) a desired behaviour (Ajzen, 1991). In-
tentions and motivations are terms used interchangeably in
behaviour change literature and thought to be key cognitive aspects
determining whether an individual actually adopts a behaviour or
not (Godin et al., 2008).
2.2. Setting and sample
Criterion sampling (Palinkas et al., 2015; Palys, 2008) was used
to ensure the selection of rich insights from all midwifery educators
working in the PNG Maternal and Child Health Initiative. Eighteen
PNG national and 15 international educators who had been
involved in the initiative from August 2012, up until the data
collection period in March 2015 were invited via email to
contribute to the research. Thirteen national and 13 international
educators consented to participate and were interviewed. Two in-
ternational midwifery educators and one national educator were
not available for interview.
Participants were provided with an information sheet and a
consent form a month prior to data collection and were informed
that participation was voluntary. The date and time of data
collection was negotiated with the participant.
2.3. Data collection
Twenty-six individual in-depth semi-structured interviews
were conducted in March 2015. Nineteen participants were inter-
viewed in person during a two and a half day midwifery education
workshop at a conference venue for logistical and security reasons
68 F. West et al. / Nurse Education in Practice 25 (2017) 66e73
not far from the capital city of Port Moresby in PNG.
Three midwifery educators who consented to participate and
were geographically located outside Port Moresby at the time of the
workshop were contacted by telephone. Four midwifery educators
not attending the workshop were interviewed using Skype at a
time and setting that was convenient for them (see Table 1).
Questions for the individual in-depth semi-structured in-
terviews were developed by the research team informed by an
initial scoping review of midwifery capacity building (West et al.,
2015) and the TPB. The interview questions were reviewed by
midwifery researchers from Australia and PNG and minor changes
were made to simplify the language and introductory questions to
put the participant at ease. A sample of the interview questions
were provided to the participants in the participant information
sheet prior to data collection. All interviews were conducted in
English and were digitally recorded and transcribed verbatim as
soon as possible after the interview.
2.4. Data analysis
Data were analysed using thematic analysis (Braun and Clarke,
2006). A combination of deductive and inductive methods of cod-
ing were employed to identify repetitions, similarities, differences,
exceptions and causal relations in the data (Mills et al., 2010; Ryan
and Bernard, 2003). A deductive approach informed by the TPB was
used to identify patterns reflective of the educator's attitude, the
presence of social norms and perceived behaviour controls which
influenced their ability to improve midwifery practice.
Additional codes were then inductively applied to data which
did not initially appear to fall into the TPB categories during second
and third round open coding (Ryan and Bernard, 2003). It was at
this stage that distinct themes became more apparent, each with
relevant sub-themes. All authors reviewed and agreed upon the
final seven themes which were named using gerunds to describe
the general conceptual action which emerged from the data which
is one way of describing the processes of human action (Saldana,
2009).
Ethical approval for this study was obtained from the university
and the Papua New Guinea Medical Research Advisory Committee
(MRAC). Written and verbal consent was obtained from all study
participants.
3. Findings
There were seven themes that described the impact of the
approach used in the MCHI to strengthening midwifery education.
The first three themes described the enabling individual attributes,
collaborative skills and processes which were used and perceived
positively by the educators. The next four themes explore aspects
related to individual, collaborative and contextual influences which
were perceived to create challenges or constrain the individual's
ability to have improved midwifery teaching. A visual map of the
themes is displayed in Fig. 1.
Table 1
Methods of data collection.
Interviews Face to face interview in PNG
International 9 1
National 10
Total 19
3.1. Demographic information
The average age range of the participants was between 47 and
57 years old. There was one male and 25 female participants. This
distribution accurately reflects the gender distribution of
midwifery educators working in PNG (Papua New Guinea National
Government, 2009). International educators were from Australia,
New Zealand and Malawi. All national educators were from either
coastal, island or highland regions of Papua New Guinea reflecting
geographical and cultural diversity within the sample.
All participants were currently working or had worked within
the previous two years in the initiative. Participants had an average
of 27 years of nursing and midwifery experience (international: 31
years and national: 13 years). Participants had an average of 15
years (international: 19 and national: 11 years) of experience
working in midwifery education. The national educators were from
all four education institutions located in both urban and more
remote regions of PNG.
All the national educators had completed their midwifery edu-
cation in PNG and the language of instruction was a mixture of
English, local dialects and Tok Pisin which is a form of Melanesian
Pidgin English. International educators all completed their
midwifery education in well-resourced high income countries
(Australia, New Zealand and Scotland) and the language of in-
struction was English. Five international and three national edu-
cators had completed a Master's level degree, the remainder of
participants had completed postgraduate study.
The findings are outlined according to the themes that provided
insight into the factors that enabled or constrained behavioural
change in relation to capacity building.
3.2. Enabling factors
The themes in this section highlight the individual and rela-
tionship factors perceived as enabling improved midwifery teach-
ing and learning.
3.2.1. Knowing your own capabilities
Participants spoke of how knowing their capabilities helped
them in their role by seeking relevant learning opportunities and
sharing their strengths with colleagues.
For example, a national educator said:
I've been asking if PNG midwifery educators could have an
attachment program in the hospital so we could enhance the
skills that we have. Like evidence based practice and the new
technologies and all that, as educators we should have the skills
on that. (National educator)
Some national and most international educators perceived that
they had adequate clinical skills for the role of midwifery educator.
Others stated that they would have felt more confident with extra
clinical experience. Most national and international educators
stated they would have felt more prepared if they had had a formal
adult teaching qualification so that they could facilitate learning
more effectively.
Telephone interview from within PNG Skype interview to Australia Total
3 13
2 1 13
3 4 26
 F. West et al. / Nurse Education in Practice 25 (2017) 66e73
Fig. 1. Visual map of Phase 1 themes.
3.2.2. Being able to build relationships
Participants noted that the time taken to build relationships was
important to develop trust and respect and enabled improved in-
formation exchange. Working together to prepare lesson plans, co-
teach or facilitate clinical practice in the practicum sites provided
an increased opportunity for collaboration which was valued by
both groups of educators.
International educators stated that working side-by-side
enabled them to receive important information on the culture
and context and national educators expressed that they gained
confidence to implement new methods of teaching in the educa-
tion institution or the clinical practicum site.
An international educator expressed how relationship building
during the workshops enabled improved teaching, saying:
I think the workshops are very good, the national educators
together with us and we are all doing the same thing, and
bringing the clinicians (to the workshops) as well. It helps build
relationships in the hospital which allows better teaching in the
hospital. (International educator)
Face-to-face communication during the midwifery education
workshops enabled a personal connection to be made and national
educators expressed they were more likely to collaborate with each
other after meeting in this way.
3.2.3. Being motivated to improve the health status of women
Participants were motivated to strengthen midwifery teaching
as they knew it would improve maternal and newborn survival.
They were aware of the high rate of maternal and newborn mor-
tality in PNG and most had personal experiences of maternal death.
A national educator expressed that this experience was a moti-
vating factor for her to improve midwifery teaching when she said:
… the experience of maternal death back then was my moti-
vation to use my knowledge to help mothers in PNG ever since.
It was a very emotional time for me. (National educator)
National educators felt they had influence over a larger number
of the midwifery workforce when compared to previous roles
working in clinical or administrative roles. A national educator
explained it like this:
69
If I'm the Director of Nursing Services at this hospital, then I'm
not passing the knowledge and skills that I have to many people
so that they will go out there and help reduce the high MMR and
treat people well … So I get back to teaching so when I teach, I
teach 20 students, 30, 40, 50 … I share my experience so I can
help people instead of just working at this little hospital. (Na-
tional educator)
The three themes perceived as enabling midwifery educators
were associated with individual and relationship level factors
which strengthened their ability to work together in an interna-
tional partnership towards a common goal.
3.3. Constraining factors
The four themes identified as constraining midwifery educators
were related to the relationship, preparation of individuals for
working together and the presence of an enabling environment.
3.3.1. Having a mutual understanding of capacity building
The definition of capacity building was not interpreted the same
way by the participants. The perception of the international edu-
cators as replacement workforce limited the collaborative oppor-
tunities inherent in a capacity building model. This was expressed
clearly by a national educator:
We need a written expectation within this phase of capacity
building … this would be helpful because I think some national
people may just be thinking that these international people are
just additional hands to help us. (National educator)
International educators were expecting to work alongside a
national colleague to support their teaching but often filled staffing
gaps and taught students independent of their national colleagues.
Both international and national educators expressed that they
learnt how to work together as the initiative progressed but that it
would have been helpful to have clear guidelines at the beginning
of the initiative to guide the capacity building process. This finding
indicated that even if each group of educators had a job description
to guide their independent work, they required some additional
tools to prepare them for working together.
Participants expressed that they felt other stakeholders did not
understand the role of the international educators which
70 F. West et al. / Nurse Education in Practice 25 (2017) 66e73

constrained the capacity building relationship. This was expressed educators were not always able to provide feedback in a culturally
by a national educator in the following way: sensitive way and were occasionally too outspoken. Although
speaking frankly was culturally appropriate in the international
I have had some of my colleagues from the National Department
educator's home country, this way of speaking was contrary to the
of Health say ‘these white meris (white women) come up to our
indirect communication style typical in PNG culture (Saffu, 2003).
office and I was wondering what this was for?’ There was no
The national educators found it difficult to give feedback to their
communication and preparation to say ‘this is what capacity
peers within the culturally enforced hierarchy. For example, it was
building is’ and what should we do? (National educator)
seen as important to ‘keep the peace’ and this social norm con-
strained the national educator's ability to provide constructive
feedback and improve midwifery teaching and clinical facilitation
of students.
3.3.2. Preparing stakeholders for working together
The national educators felt that they needed to improve their
Working together was not always easy and required further
spoken and written English language skills in order to be more
preparation. Some national educators expressed that they were not
effective in their role. A national educator expressed that she felt
consulted regarding whether they wanted to work in a partnership
her teaching capacity was constrained due to the lack of English
model with international midwifery educators and this affected
fluency:
their willingness to collaborate. A national educator stated:
I think a big issue is English. If we are good in English we could
The challenge I see in partnering is different types of people and
guide the students effectively so they could be academic as well
you try and make them work together. It is really difficult at
as clinicians. (National educator)
times. There are some, you partner them and there is no prob-
lem. There are some and you partner them and lots and lots of
problems. (National educator) The key cultural factors were related to individuals not being
responsive to the cultural norm for communication and not having
proficiency in a common language. These factors were viewed as
Some participants expressed that they did not feel totally
constraining educator's capacity to improve teaching.
confident in all aspects required of the role and this was the case for
both national and international educators although for different
aspects. National educators had not had the opportunity for higher
3.3.4. Needing a supporting environment
education and thus were learning ‘on the job’. A national educator
Participants stated that there were not enough national
expressed this by saying:
midwifery educators employed in their faculty and this challenged
I see the PNG educators as really good clinicians and most of the their ability to improve midwifery teaching capacity. An interna-
educators have not been to formal training in teaching before. So tional educator commented on how low staffing numbers impacted
how do we impart it to the students, the knowledge and skills? upon her role:
(National educator)
The universities have to have a full complement of staff. It is
hard to capacity build when you don't have many people to
Equally, the international educators were required to work in an capacity build with. (International educator)
advanced leadership, teaching and clinical practice level than what
was expected in their well-resourced home countries. An interna-
National participants felt unsupported by the education insti-
tional educator expressed her perception of needing an education
tution in terms of their career progression and role development
qualification in this way:
and stated that they had few opportunities for professional
I've never done any formal education training … so I've been mentorship or guidance. A national educator expressed the lack of
learning on the hoof really. I've done a gazillion courses over my support within her faculty:
career … but I've never done any formal post-grad. I think the
When I first started at the education institution (in an education
best thing is for people to do some formal training to have some
role), I found it quite difficult. There was no one there to mentor
understanding of how lessons are set and how people learn
me, even though my colleagues were there, they were more into
(International educator)
their own subjects. (National educator)

Some national educators acknowledged that their rote learning

It was felt that the attitude and capacity of the clinicians who
teaching style was not effective to produce a quality midwifery
supported student learning and worked together with the
graduate and were willing to learn other methods of facilitating
midwifery educators did not create an enabling environment for
learning. Other national educators found it challenging to adapt to a
quality teaching and learning. An international educator expressed
less didactic way of teaching and expressed it like this:
it in this way:
I follow one step and when I do that every time, it is like I
We're teaching the students one thing and then they are going
memorize it. But if I tend to do other steps from what I have
to the clinical area and being taught something else or they are
been doing, I cannot get it straight. It is all over my mind. I have
going to the clinical area and not being supported by the staff,
to do the one sequence over and over again. (National educator)
they don't see it as their role to teach students, they see it as our
role as educators. (International educator)

3.3.3. Knowing how to adapt to a different culture Issues with the capacity of the midwifery regulatory body and
Cultural norms affecting communication and adaptation were hospital administration to control the quality of clinical midwifery
identified a constraint to improving midwifery teaching and practice were seen as constraining environmental factors. There
learning. The national educators perceived that the international were few disciplinary measures in place for absenteeism or
 F. West et al. / Nurse Education in Practice 25 (2017) 66e73
unprofessional conduct and educators were challenged on a daily
basis working with limited resources which created a stressful
working environment. In addition, there was a lack of infrastruc-
ture in some education institutions to access up-to-date internet-
based resources to improve teaching and learning.
4. Discussion
Successful international partnerships for capacity building are
dependent on many factors. This study has identified factors
influencing behaviour that can be attributed to the attitude of in-
dividuals, social norms and perceived behavioural control which
are variables described in the TPB. Other findings of this study
indicate that factors associated with the process of capacity
building, such as the ability to adequately prepare for expectant
roles and the creation of a supportive professional environment are
also influential.
Two themes were identified that are aligned with the attitude of
midwifery educators towards capacity building, namely knowing
your own capabilities and being motivated indicating that charac-
teristics of self-awareness and self-regulation are important. Sup-
porting midwifery educators to better develop critical self-
reflection skills could therefore be a useful way forward to
improve teaching (Abdul Malek and Budhwar, 2013; Fee et al.,
2013; Rhodes and Rumsey, 2016). This is supported by research in
high-income countries (Hunter and Warren, 2014) which empha-
sizes that competence is only related in part to the possession of
clinical skills and that the attitude of the care provider is also
critical. When educators are supported to reflect on their individual
capabilities and are supported to develop them it enhances an
attitude of confidence in oneself and in others (Girot and Enders,
2003; Michie et al., 2008).
The participants in our study identified various factors that
motivated them to work together to improve midwifery teaching
and learning. One motivating factor was the awareness of the
disparity between rural and urban maternal health outcomes.
Midwifery educators stated that they wanted to improve the
quality of midwifery care in rural areas by preparing midwifery
graduates to work in a low-resource environment (UNFPA et al.,
2014). Other research (Viano et al., 2012; Webb and Sheeran,
2006) has shown that an individual's behaviour is able to be
modified once they have been made aware of their motivations by a
process of self-reflection on their attitudes toward the behaviour.
Understanding which motivating factors are shared, realistic and
achievable could provide significant insights which could aid in the
preparation of midwifery educators to work together in an inter-
national partnership (Liberato et al., 2011).
A core set of midwifery competencies have been described as
essential to the provision of high quality maternal and child health
services (Fullerton et al., 2011). The Basic Competencies for
Midwifery Practice (International Confederation of Midwives,
2013) and the Midwifery Educator Core Competencies (World
Health Organization, 2013) are useful tools that can be used to
change attitudes in preparation for capacity building partnerships.
These competencies can provide an objective benchmark for
monitoring capabilities and galvanise the commitment and moti-
vation of all partners to improve midwifery teaching (Fullerton
et al., 2011).
The three themes in the study that were mapped to the sub-
jective social norm variable of the TBP were: being able to build
relationships, having a mutual understanding of capacity building and
adapting to a different culture. These themes indicate that partici-
pants valued the importance of culturally appropriate communi-
cation between all stakeholders so that they could improve
teaching.
71
The national educators preferred building relationships as a
group and found this to be an effective way to share clinical and
pedagogical knowledge and skills. International educators appre-
ciated the opportunity to connect with each other virtually, during
regular teleconferences, email and telephone. This finding indicates
the importance of identifying the specific way in which local and
international partners interact to learn and share knowledge so
that a mixture of those methods can be incorporated into the
program (Maclean, 2013; Rhodes, 2014).
This study has identified that misunderstandings about each
partner's role and the purpose of capacity building can constrain
the partnership. Mutual understanding can be achieved by
ensuring effective collaboration across all stages of the capacity
building program cycle. This has been found to improve partner
cooperation and mutual understanding, enabling the clarification
of roles and responsibilities and the achievement of prerequisite
professional skills in preparation for the program initiation (Algeo,
2015).
Aspects of culture such language, communication style and hi-
erarchy were identified in this study as influencing the ability of
educators to improve teaching. In addition to technical expertise,
cultural competence has been noted as a key factor contributing to
the success of cross cultural partnerships in international health
settings (Fee et al., 2011; Liberato et al., 2011; Requejo et al., 2010;
Rhodes, 2014; United Nations Development Program, 2009; Van
Vianen et al., 2004; Zheng et al., 2001). Culturally competence
has been discussed in relation to the preparatory training of in-
dividuals engaged in international partnerships (Lasker, 2015;
Maclean, 2011; Rhodes and Rumsey, 2016; Rhodes, 2014). However
such competence is underpinned by cognitive, affective and
behavioural skills that are thought to be learnt over time which
implies that preparatory training alone may not be sufficient
(Holmes et al., 2015; Perry and Southwell, 2011). There is a gap in
the literature regarding what specific preparation or orientation is
necessary for individuals or organisations in the host country to feel
adequately prepared to work with their international colleagues
(Fee and Gray, 2013; Lasker, 2015; Liberato et al., 2011; Maclean,
2013). Strategies to mitigate cultural misunderstandings may
include providing national stakeholders with cultural specific
knowledge regarding the dimensions of their international col-
league's country. Embedding cultural competency indicators in the
monitoring and evaluation of capacity building programs could also
improve relationships and assist educators adapt to working in a
cross-cultural environment.
This study identified a link between how well prepared the PNG
midwifery educators felt they were to work in the capacity building
process and the amount of control they perceived they had to
implement improved teaching. Educators stated that they would
feel more prepared for the role if they had received relevant in-
formation on culture, language, technical or pedagogical skills at
the beginning of the program. A preparation or induction process
which addresses these aspects and incorporates behaviour change
theory for all stakeholders may be beneficial to provide opportu-
nities for personal and professional growth which aids educators to
feel better prepared for working in a cross-cultural partnership (Fee
and Gray, 2013; Holmes et al., 2015).
Midwifery educators in our study perceived that they were
unable to influence the institution and health system factors which
affected the quality of teaching and learning. Even though the TPB
states that intention is the proximal cause of behaviour, a sup-
portive environment must also be present in order for the behav-
iour to be realized (Webb and Sheeran, 2006). Barriers to
strengthening midwifery capacity within education institutions
have been highlighted In the literature and including a limited
number of skilled and motivated midwifery staff (UNFPA et al.,
72 F. West et al. / Nurse Education in Practice 25 (2017) 66e73
2014), a lack of necessary infrastructure to access contemporary
research evidence and inadequate supply of teaching resources and
simulation aids (West et al., 2015). It has also been identified that
appropriate leadership and governance of midwifery education
institutions and adequate workforce planning are essential factors
which contribute to strengthening midwifery teaching capacity
(UNFPA et al., 2014). Outside the education institution, the
improved functioning of midwifery regulatory and professional
association bodies could help to reduce the theory-practice gap in
clinical placement sites, regulate the midwifery scope of practice
and improve collaboration and partnership between stakeholders
(International Confederation of Midwives, 2015; Lopes et al., 2016).
Having a clearer understanding of the midwifery educator's
attitude, the degree in which social pressure influences behaviour
and the level of perceived behaviour control may allow the capacity
building process to be planned and implemented more effectively.
Individuals and organisations providing support to midwifery ed-
ucators in LMIC would be better able to contextualize the individual
preparation, partnership and environment accordingly. This may
help to ensure that the maximum benefit for both international and
national educators is achieved within the scope of the capacity
building initiative.
5. Conclusion
These findings contribute a more detailed understanding of the
factors that facilitate and constrain the ability of midwifery edu-
cators to enhance midwifery teaching and learning within the
context of a capacity building approach using international
partnerships.
Developing a model to guide the planning and implementation
of capacity building programs for midwifery education may be
useful to adequately prepare health systems and individuals to
work together to strengthen midwifery education in LMIC. Deter-
mining if these findings are applicable in other LMIC would be
useful to establish if these findings are transferable to other
contexts.
References
Abdul Malek, M., Budhwar, P., 2013. Cultural intelligence as a predictor of expatriate
adjustment and performance in Malaysia. J. World Bus. 48 (2), 222e231.
Ajzen, I., 1991. The theory of planned behavior. Organ. Behav. Hum. Decis. Process.
50, 179e211.
Algeo, C., 2015. Developing the ‘Heads and Feet’ of the Next Generation of Project
Managers. National 2015 Conference, Australian Institute of Project Manag-
ment, Hobart, pp. 12e27.
Baxter, P., Jack, S., 2008. Qualitative case study methodology: study design and
implementation for novice researchers. Qual. Rep. 13 (4 December), 544e559.
Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qual. Res. Psychol.
3, 77e101.
Brideson, G., Glover, P., Button, D., 2012. Flight nurses in Australia: maintaining their
midwifery competence - a case study. Contemp. Nurse 43 (1), 121e130.
Brodie, P.M., 2013. Midwifing the midwives': addressing the empowerment, safety
of, and respect for, the world's midwives. Midwifery 29 (10), 1075e1076.
Creswell, J.W., 2013. Research Design. Qualitative, Quantitative and Mixed Methods
Approaches, fourth ed. Sage Publications, Inc., Thousand Oaks.
Dawson, A., Nkowane, A.M., Whelan, A., 2015. Approaches to improving the
contribution of the nursing and midwifery workforce to increasing universal
access to primary health care for vulnerable populations: a systematic review.
Hum. Resour. Health 13 (97).
Fee, A., Gray, S.J., 2013. Transformational learning experiences of international
development volunteers in the Asia-Pacific: the case of a multinational NGO.
J. World Bus. 48 (2), 196e208.
Fee, A., Gray, S.J., Lu, S., 2013. Developing cognitive complexity from the expatriate
experience: evidence from a longitudinal field study. Int. J. Cross Cult. Manag. 13
(3), 299e318.
Fee, A., McGrath-Champ, S., Yang, X., 2011. Expatriate performance management
and firm internationalization: Australian multinationals in China. Asia Pac. J.
Hum. Resour. 49 (3), 365e384.
Forss, K., Maclean, G.D., 2007. The African Midwives Research Network. Sida,
Department for Democracy and Social Development, Sweden.
Fraser, D.M., Avis, M., Mallik, M., 2013. The MINT project - An evaluation of the
impact of midwife teachers on the outcomes of pre-registration midwifery
education in the UK. Midwifery 29, 86e94.
Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P.,
Ke, Y., Kelley, P., Kistnasamy, B., 2010. Health professionals for a new century:
transforming education to strengthen health systems in an interdependent
world. The Lancet 376 (9756), 1923e1958.
Fullerton, J.T., Johnson, P.G., Thompson, J.B., Vivio, D., 2011. Quality considerations in
midwifery pre-service education: Exemplars from Africa. Midwifery 27 (3),
308e315.
Girot, E.A., Enders, B.C., 2003. International educational partnership for practice:
Brazil and the United Kingdom. J. Adv. Nurs. 46 (2), 144e151.
Godin, G., Belanger-Gravel, A., Eccles, M., Grimshaw, J., 2008. Healthcare pro-
fessionals' intentions and behaviours: a systematic review of studies based on
social cognitive theories. Implement. Sci. 3 (36), 1e12.
Harder, H., 2010. Explanatory case study. In: Mills, A.J., Durepos, G., Wiebe, E. (Eds.),
Encyclopedia of Case Study Research. Sage Publications, Inc, Thousand Oaks.
Holmes, P., Bavieri, L., Ganassin, S., 2015. Developing intercultural understanding for
study abroad: students' and teachers' perspectives on pre-departure intercul-
tural learning. Intercult. Educ. 26 (1), 16e30.
Homer, C.S.E., Friberg, I.K., Augusto Bastos Dias, M., ten Hoope-Bender, P., Sandall, J.,
Speciale, A.M., Bartlett, L.A., 2014. The projected effect of scaling up midwifery.
The Lancet 384, 1e12.
Hunter, B., Warren, L., 2014. Midwives' experiences of workplace resilience.
Midwifery 30, 926e934.
International Confederation of Midwives, 2013. Association Core Documents. ICM,
The Hague, viewed 23 October 2013. www.internationalmidwives.org.
International Confederation of Midwives, 2015. Midwifery Services Framework.
Guidelines for Developing SRMNAH Services by Midwives. Field-test version 17
March 2015. ICM, The Hague.
Labonte, R., Laverack, G., 2001. Capacity building in health promotion, Part 1: for
whom? And for what purpose? Crit. Public Health 11 (2), 111e127.
Lasker, J.N., 2015. Global Health Volunteering; Understanding Organizational Goals,
27. International Society for Third-Sector Research and The Johns Hopkins
University, pp. 574e594.
Lavender, T., Lugina, H., Vido, P., Chimwaza, A., Bedwell, C., Donovan, P., Kohi, T.,
Dlammani, P., Tsekiri, E., Msuya, M., 2009. Capacity building to reduce maternal
and neonatal morbidity and mortality. Afr. J. Midwifery Women's Health 3 (4).
Lemay, N.V., Sullivan, T.B.J., Peabody Perry, C., 2012. Reaching remote health
workers in Malawi: baseline assessment of a pilot mHealth intervention.
J. Health Commun. 17, 105e117.
Liberato, S.C., Brimblecombe, J., Ritchie, J., Ferguson, M., Coveney, J., 2011. Measuring
capacity building in communities: a review of the literature. BMC Public Health
11 (850), 1e10.
Lopes, S.C., Nove, A., ten Hoope-Bender, P., de Bernis, L., Bokosi, M., Moyo, T.N.,
Homer, C.S.E., 2016. A descriptive analysis of midwifery education, regulation
and association in 73 countries: the baseline for a post-2015 pathway. Hum.
Resour. Health 14 (37), 1e12.
Maclean, G.D., 2011. Short-term international midwifery consultancy: evaluating
practice. Br. J. Midwifery 19 (12), 814e819.
Maclean, G.D., 2013. Electives and International Midwifery Consultancy: a Resource
for Students, Midwives and Other Healthcare Professionals. Tiger Stripes and
Tears. Quay Books, London.
Michie, S., Johnston, M., Francis, J., Hardeman, W., Eccles, M., 2008. From theory to
intervention: mapping theoretically derived behavioral determinants to
behaviour change techniques. Appl. Psychol. 57 (4), 660e680.
Mills, A.J., Durepos, G., Wiebe, E., 2010. Thematic Analysis', Encyclopedia of Case
Study Research. Sage Publications, Inc., Thousand Oaks.
Palinkas, L.A., Horwitz, S.M., Green, C.A., Wisdom, J.P., Duan, N., Hoagwood, K., 2015.
Purposeful sampling for qualitative data collection and analysis in mixed
method implementation research. Adm. Policy Ment. Health 42, 533e544.
Palys, T., 2008. Purposive sampling. In: Given, L.M. (Ed.), The SAGE Encyclopedia of
Qualitative Research Methods. Sage Publications, Inc., Thousand Oaks.
Papua New Guinea National Government, 2009. Papua New Guinea Demographic
and Health Survey 2006 National Report. National Statistical Office, Port
Moresby.
Perry, L.B., Southwell, L., 2011. Developing intercultural understanding and skills:
models and approaches. Intercult. Educ. 22 (6), 453e466.
Renfrew, M.J., McFadden, A., Bastos, M.H., Campbell, F., Channon, A.A., Cheung, N.G.,
Silva, D.R.A.D., Downe, S., Kennedy, H.P., Malata, A., McCormick, F., Wick, L.,
Declercq, E., 2014. Midwifery and quality care: findings from a new evidence-
informed framework for maternal and newborn care. The Lancet 384, 1e17.
Requejo, J.H., Toure, K., Bhutta, Z.A., Katz, I., Zaidi, S., de Francisco, A., 2010. Regional
collaborations as a way forward for maternal, newborn and child health: The
South Asian Healthcare Professional Workshop. J. Health. Popul. Nutr. Oct 28
(5), 1e7.
Rhodes, D., 2014. Capacity across Cultures. Global Lessons from Pacific Experiences.
Inkshed Press Pty Ltd, Victoria.
Rhodes, D., Rumsey, M., 2016. An innovative approach to supporting health service
delivery in the pacific appears to be ticking health policy and development
boxes. Health Syst. Policy Res. 3 (1), 1e6.
Ryan, G.W., Bernard, H.R., 2003. Techniques to identify themes. Field Methods 15
(1), 85e109.
Saffu, K., 2003. The role and impact of culture on South Pacific island entrepreneurs.
Int. J. Entrep. Behav. Res. 9 (2), 55e73.
 F. West et al. / Nurse Education in Practice 25 (2017) 66e73
Saldana, J., 2009. The Coding Manual for Qualitative Researchers. Sage, Los Angeles.
ten Hoope-Bender, P., De Bernis, L., Campbell, F., Downe, S., Fauveau, V., Fogstad, H.,
Homer, C.S.E., Powell Kennedy, H., Matthews, Z., McFadden, A., Renfrew, M.J.,
Van Lerberghe, W., 2014. Improvement of maternal and newborn health
through midwifery. The Lancet 384, 1e10.
UNFPA WHO ICM, 2014. The State of the World's Midwifery. A Universal Pathway. A
Woman's Right to Health. UNFPA, WHO, ICM, New York.
UTS World Health Organisation Collaborating Centre for Nursing Midwifery &
Health Development, 2014. Phase 1: Final Report PNG Maternal and Child
Health Initiative (MCHI). UTS, Sydney.
Van Vianen, A.E.M., De Pater, I.E., Kristof-Brown, A.L., Johnson, E.C., 2004. Fitting in:
surface- and deep-level cultural differences and expatriates' adjustment. Acad.
Manag. J. 47 (5), 697e709.
Viano, K., Holbrook, J., Rannikmae, M., 2012. A case study examining change in
teacher beliefs through collaborative action research. Int. J. Sci. Educ. 35 (1),
1e30.
Webb, T.L., Sheeran, P., 2006. Does changing behavioral intentions engender
behavior change? A meta-analysis of the experimental evidence. Psychol. Bull.
132 (2), 249e268.
West, F., Homer, C., Dawson, A., 2015. Building midwifery educator capacity in
73
teaching in lower and lower-middle income countries. A review of the litera-
ture. Midwifery 33, 12e23.
World Bank, 2011. Reproductive Health at a Glance. Papua New Guinea. viewed
October 2016. www.worldbank.org.
World Bank, 2014. World Bank List of Economies. viewed September 2016. www.
worldbank.org.
World Health Organization, 2013. Midwifery Educator Core Competencies. WHO,
Geneva.
World Health Organization, 2014. Global Strategy for Women's and Children's
Health. WHO, Geneva.
World Health Organization, 2015. The Global Strategy for Women's, Children's and
Adolescents' Health 2016-2030. WHO, Geneva.
Yamey, G., 2012. What are the barriers to scaling up health interventions in low and
middle income countries? A qualitative study of academic leaders in imple-
mentation science. Glob. health 8 (11), 1e11.
Yin, R.K., 2009. Case Study Research Design and Methods, fourth ed., vol. 5. Sage,
Los Angeles.
Yin, R.K., 2012. Applications of Case Study Research, third ed. Sage, Los Angeles.
Zheng, X.X., Hinshaw, A.S., Yu, M.Y., Guo, G.F., Oakley, D.J., 2001. Building interna-
tional partnerships. Int. Counc. Nurses 48, 117e121.