research paper on training need analysis

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BMC Med Educ

Training needs assessment: tool utilization and global impact

Adelais markaki.

1 PAHO/WHO Collaborating Center for International Nursing, Birmingham, AL USA

2 School of Nursing, University of Alabama at Birmingham, 1701 University Boulevard, Birmingham, AL 35294 USA

Shreya Malhotra

3 Stanford University, Stanford, CA USA

Rebecca Billings

Associated data.

All data generated or analyzed during this study are included in this published article.

Global demand for standardized assessment of training needs and evaluation of professional continuing education programs across the healthcare workforce has led to various instrumentation efforts. The Hennessy-Hicks Training Needs Analysis (TNA) questionnaire is one of the most widely used validated tools. Endorsed by the World Health Organization, the tool informs the creation of tailored training to meet professional development needs. The purpose of this project was to describe TNA tool utilization across the globe and critically appraise the evidence of its impact in continuous professional development across disciplines and settings.

A systematic integrative literature review of the state of the evidence across PubMed, Scopus, CINAHL, and Google Scholar databases was carried out. Full-text, peer reviewed articles and published dissertations/theses in English language that utilized the original, adapted or translated version of the TNA tool were included. Selected articles were appraised for type and level of evidence.

A total of 33 articles were synthesized using an inductive thematic approach, which revealed three overarching themes: individual, team/interprofessional, and organizational level training needs. Included articles represented 18 countries, with more than two thirds involving high-income countries, and one third middle-income countries. Four studies (12.1%) used the original English version instrument, 23 (69.7%) adapted the original version, and 6 (18.2%) translated and culturally adapted the tool. Twenty-three studies targeted needs at the individual level and utilized TNA to determine job roles and responsibilities. Thirteen articles represented the team/interprofessional theme, applying the TNA tool to compare training needs and perceptions among professional groups. Last, three articles used the tool to monitor the quality of care across an institution or healthcare system, demonstrating the organizational training needs theme.

Conclusions

Overall evidence shows that the TNA survey is widely used as a clinical practice and educational quality improvement tool across continents. Translation, cultural adaptation, and psychometric testing within a variety of settings, populations, and countries consistently reveals training gaps and outcomes of targeted continuous professional development. Furthermore, it facilitates prioritization and allocation of limited educational resources based on the identified training needs. The TNA tool effectively addresses the “know-do” gap in global human resources for health by translating knowledge into action.

Over the last 25 years, a trained workforce has been at the core of success for any organization or industry. Appropriate and systematic approaches to training have been shown to result in skills improvement, which in turn raise the quality of employees [ 1 ]. Assessing and understanding workforce training needs ensures confidence, know-how, and a variety of new skills that bolster preparedness on an individual and team-based level in any organization [ 2 ]. Given the rapid technological advances, persisting workforce shortages, increased disease burden, and shrinking resources, healthcare organizations must methodically survey existing and expected performance levels of their staff [ 3 ]. Yet, evaluation of training and development processes, used until the mid-90’s, showed that healthcare professionals were not acquiring the necessary skills to successfully perform their jobs [ 4 ]. Similarly, healthcare organizations often did not carry out adequate assessments of training needs, due to limited time and resources, or failure to use research evidence to inform practice [ 5 ]. Consequently, training needs analysis (TNA) must be viewed and carried out in the context of existing healthcare systems to be consistent with the needs of employees and relevant to the ever-changing demands of organizations [ 6 ].

Literature on healthcare employee training needs has evolved considerably. Several TNA models were developed to understand and address training deficiencies in the workplace through data collection and analysis from both employees and employers [ 7 ]. The traditional model focuses on job behavior and task analysis, using surveys and formal interviews to gather data [ 8 ]. Its main drawback, besides being time-consuming, is its focus on predetermined outcomes which precludes the possibility of unplanned learning taking place. As an alternative, the practical model considers a trainer-centered, demand-led or supply-led “pedagogical approach” to TNA [ 9 ]. Whilst this model helps the TNA coordinator select the appropriate approach for the desired outcome, it does not provide any guidance as to how to conduct an assessment that is both comprehensive and effective. As a result, this approach could be a waste of time and resources.

Acknowledging the above challenges and limitations, investigators from the United Kingdom (UK) in 1996 initiated efforts towards a cost-effective and psychometrically sound TNA tool for the healthcare industry. The Hennessy-Hicks Training Needs Analysis (TNA) Questionnaire, referred as “TNA” from here on after, was developed to identify individual training needs, organizational requirements, and targeted training strategies [ 10 , 11 ]. Since its development, the TNA tool has been psychometrically tested and used for a variety of purposes among several settings and populations. It has a proven track record for use with primary healthcare teams, district and practice nurses, nurse practitioners (NPs), and health visitors in the UK [ 10 – 13 ]. The TNA has been shown to minimize response bias and provide reliable information about current performance levels, skill areas most in need of further development, and how to best achieve optimal results. This knowledge facilitates organizations with priority-setting and policy development, as well as with evaluation of their continuous professional development (CPD) programs.

In 2011, the TNA developers licensed the tool to the World Health Organization (WHO) for online use and dissemination through the Workforce Alliance website [ 14 ]. With rising calls for evaluating training and competency to regulate nursing practice in the Americas [ 15 ], stemming from the “Global strategy on human resources for health: Workforce 2030” [ 16 ], our motivation for this project was twofold. First, the lead investigator’s experience with translating, adapting, and applying the TNA instrument in another language, as part of an action research PhD dissertation. Second, the team’s affiliation with a WHO Collaborating Center (WHOCC) that promotes global capacity building for nurses and midwives as well as educational quality improvement (QI). Therefore, this integrative review aimed to describe TNA tool utilization across the globe and critically appraise the evidence of its impact in CPD across disciplines and settings.

The Hennessy-Hicks TNA Questionnaire and Manual [ 14 ] was accessed through the WHO Workforce Alliance website and was carefully reviewed to determine initial intended use. The tool consists of a one-page demographics section, an open-ended question, and a 30-item questionnaire which covers core clinical tasks, arranged into five sub-sections; research/audit, administrative/ technical, communication/teamwork, management/supervisory, and clinical activities. Respondents rate each item on a seven-point scale according to two criteria: “ How critical the task is to the successful performance of the respondent’s job” and “ How well the respondent is currently performing the task.” Ratings for criterion A (Criticality Index) provide an overall occupational profile of the job, and those for criterion B (Skill Index) the level of performance. Subtracting the scores (criterion A – criterion B) in each task provides a Training Needs Index. The accompanying manual offers instructions, data analysis, and customization for use in one’s own environment.

To allow for cross-country and cross-setting comparisons, the investigators adopted the Knowledge to Action (KTA) Framework developed by Graham et al. [ 17 ]. Knowledge translation is “a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge” [ 18 ]. The KTA process conceptualizes the relationship between knowledge creation and action as a “funnel”. Knowledge is increasingly distilled before it is ready for application whereas, the action cycle represents the activities needed for knowledge application and integration [ 17 ]. By translating knowledge into action, researchers can effectively address the “know-do” gap in healthcare practice [ 19 ].

Search strategy – eligibility criteria

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to in the conduct and reporting of this systematic integrative review [ 20 ]. An electronic database search in PubMed, Scopus, CINAHL, and Google Scholar was performed using the following strategy: ((“Surveys and Questionnaires”[Mesh] OR tool* OR measure* OR questionnaire* OR survey* OR scale* OR instrument*) AND (Hennessy OR Hicks OR Hennessy-Hicks OR “Hennessy-Hicks Training Needs Assessment Questionnaire”) AND (nurs* OR training-needs)).” All full-text, peer reviewed articles, dissertations or theses published in English language since 1996 were included. Additionally, a targeted manual search of grey literature and listed references was carried out. A total of 289 articles were retrieved and duplicates were removed with the use of Sciwheel Reference Manager. The resulting 265 articles were first screened by title/abstract, and then, 97 full-text articles were assessed for eligibility. During screening and eligibility steps, inclusion was determined if any of the following content-specific criteria were met: a) study using the original TNA tool, b) psychometrics study carrying out translation and/or cultural adaptation of the TNA tool in other languages or countries, and c) study applying or integrating an adapted TNA version. The above search strategy, along with reasons for excluding articles, is depicted in Fig. 1 .

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PRISMA Search Strategy for TNA Tool

Data extraction and quality appraisal

Initial title and abstract screening was conducted by an independent investigator (SM), with full-text article assessment for eligibility and data extraction carried out by two independent investigators (SM, LT). Any conflicting votes on eligibility of an article were resolved by a third investigator (AM). Appraisal of level of evidence was based on the adapted Rating System for the Hierarchy of Evidence [ 21 , 22 ]. The World Bank Atlas was followed for country classification by income level (high, middle or low) [ 23 ]. An inductive thematic analysis of the literature sample was carried out. Interprofessional education (IPE) and collaborative practice were operationalized based on the Framework for Action on Interprofessional Education and Collaboration , developed by WHO [ 24 ]. Hence, both terms ‘interdisciplinary’ and ‘multidisciplinary’, often used interchangeably, were captured. Given the systematic review methodology of this study, no study approval was required.

A total of 33 articles, published within the last 25 years (January 1996–May 2020), met our inclusion criteria and are presented in Table 1 . A summary of their characteristics and appraised evidence is shown in Table 2 . The majority of the articles (87.9%) were original research, 9.1% were dissertations or theses, and 3% posters. Thirty-two (97%) of the studies were descriptive or mixed methods (level VI evidence), and one (3%) was an expert opinion (level VIII). Study populations included nurses (72.7%), physicians (12.1%), other healthcare professionals (30%), and health insurance employees (3%). Settings ranged from primary healthcare (57.6%), to acute care (51.5%), and other organizations (6.1%) or companies (3%). As shown in Table 3 , a total of 18 countries were represented, with the majority originating from the UK. More than two thirds (69%) focused on high-income countries (HIC), 28% on middle-income countries (MIC), and only 3% on low-income countries (LIC).

Characteristics of studies using the Hennessy-Hicks TNA tool ( n = 33)

a Level of evidence appraisal based on the adapted Rating System for the Hierarchy of Evidence [ 21 , 22 ]

b Themes: Individual, Team/Interprofessional (IP), Organizational

Summary of characteristics and evidence appraisal ( n = 33)

a Some articles involved more than one study population or study setting

Classification of TNA use by country income level and theme

a Income country classification by World Bank [ 23 ]

b Some articles involved more than one country

In terms of TNA tool use, 4 (12.1%) studies used the original English version instrument, 23 (69.7%) adapted the English version, and 6 (18.2%) translated and culturally adapted the tool. Translation and cultural adaptation of the original TNA was carried out in the following languages/countries: a) Bahasa Indonesian - tested among community nurses and midwives in Indonesia [ 31 – 33 ]; b) Greek - tested among rural primary care nurses, midwives, and health visitors in Greece [ 45 , 46 ]. In addition, a modified version of TNA was translated and culturally adapted into the following languages/countries: a) Kiswahili – tested among reproductive, maternal, and newborn healthcare workers in Mwanza, Tanzania [ 48 ]; b) Bulgarian, Polish, Italian, Albanian, and Romanian – tested among formal and informal caregivers across European Union countries and immigrant communities [ 50 ]. Furthermore, a thematic analysis revealed the following three levels in training needs analysis: a) individual level; b) interprofessional or team/unit level; and c) organizational level.

Individual training needs analysis

As listed in Table Table1, 1 , a total of 17 studies centered on identifying or targeting needs at the individual level within a specific population of interest across a variety of settings [ 8 , 12 , 13 , 25 , 30 , 32 , 33 , 37 – 39 , 41 – 44 , 49 , 50 , 53 ]. Nurses, physicians, midwives, and other healthcare professionals were studied in primary healthcare, acute care, healthcare organizations, and other businesses. All 17 articles applied the TNA tool to determine specific job roles and responsibilities within the targeted setting. Hence, an individual’s perceptions about which tasks were most important for performing their jobs were assessed and captured in column A of the TNA tool. For example, Hicks and Tyler [ 38 ] used the tool to determine the required education for family planning nurses in the UK, analyzing the tasks these nurses performed, while also allowing them to indicate their training needs. By comparing the roles of the family planning nurse with the family planning nurse prescriber, the investigators determined the nuances that distinguished the two roles in two consecutive studies [ 38 , 53 ].

Eight articles determined job profile differences in a variety of geographical locations [ 12 , 13 , 30 , 32 , 33 , 38 , 50 , 53 ]. Four of these articles compared training needs across different countries or regions; within the UK, USA, and Australia [ 30 ], across Indonesia [ 32 , 33 ], and across five European countries [ 50 ]. For example, Pavlidis et al. [ 50 ] determined the differences in caregivers’ perceived training needs across the UK, Greece, Bulgaria, Poland, and Italy. Four main training needs were reported as contributing to quality care improvement: a) basic nursing skills; b) specialization in specific conditions (such as diabetes, stroke, dementia); c) training in advanced health care systems; and d) training in psychology-related skills, such as time management, emotion regulation, and communication [ 50 ]. Targeting those skills was deemed to improve European caregivers’ capacity in the health and social services sectors.

Existing knowledge gaps, and the most effective training methods to meet individual training needs, were identified across all articles. For example, a study carried out in Ireland, determined medical doctors’ training needs to inform professional development courses [ 43 ]. Workload/time organization and stress management were identified as the most pressing needs, while doctor-patient communication was ranked highest for importance and level of current performance. The TNA tool allowed for setting priorities that best met individuals’ training needs, and facilitated managers, local governments to allocate scarce budgets and resources to improve the quality of health care [ 43 ]. Similarly, a dissertation study of South African managers in public hospitals revealed that a combination of formal and informal training, enhanced by qualitative research, was the best strategy [ 49 ].

Team/Interprofessional training needs analysis

A total of 13 articles exhibited the team/IP training needs theme, encompassing more than one professional group or focusing on a team or unit as a whole [ 26 , 28 , 29 , 31 , 34 , 35 , 40 , 45 , 46 , 48 , 51 , 52 , 54 ]. Target populations included nurses, physicians, and other healthcare professionals across acute and primary care, as well as healthcare institutions. Twelve of the articles were descriptive, qualitative, or mixed methods studies (level VI evidence) whereas, one was an opinion article (level VIII evidence) [ 34 ].

Articles under this theme utilized the TNA tool for a wide variety of purposes, including to monitor and optimize quality of care. For instance, Singh and colleagues [ 52 ] utilized the TNA tool at a tertiary care hospital in India to evaluate nurses’ training needs. They identified patient care, research capacity, managerial/administrative, and communication as the highest priorities [ 52 ]. Other investigators used the tool to determine perception of job roles by nurses and their managers. TNA developers, Hicks and Hennessey [ 35 ], used the tool to define the newly established NP role in the UK, providing an operational definition and specific training needs to be targeted. The researchers surveyed all nurses working at advanced clinical levels within an acute sector of the National Health System (NHS) trust. Their triangulation results indicated overall consensus between the nurses and their managers, regarding both the definition of the NP role and the essential training requirements, with somewhat differing opinions by the medical staff [ 35 ]. Subsequently, implications in regulating educational provision for NPs in the UK emerged.

The TNA tool was also used to compare training needs and perceptions between different professional groups in the clinical setting, thus allowing for greater analysis of job roles and responsibilities. For instance, Markaki et al. [ 46 ] used the tool in Greek primary healthcare centers to determine the occupational profile differences between nurse graduates from 2-year programs and graduates from 3- or 4-year programs. Collected data were then used to determine training gaps to be targeted by future interventions. Determination of training needs at all levels allowed for budgetary analysis and resource allocation for optimum results. Hicks and Hennessy focused on improving the capacity of the NHS trust and its employees by identifying the training needs of practice nurses [ 34 ]. In this 1997 study, practice nurses considered communication and teamwork to be the most important aspects of their job, and there was overlap in the training needs identified by the nurses themselves and by their managers. In 2005, Hicks and Thomas [ 40 ] analyzed the training needs among professionals delivering community sexual health services and used the data to recommend additional courses within the allocated budget. Similarly, Mwansisya et al. [ 48 ] surveyed reproductive, maternal and neonatal healthcare workers within eight districts in Tanzania and provided a baseline of training needs in a low middle-income country. Another study, carried out at a School of Dentistry in a Sudanese university, showed that faculty and staff prioritized academic student supervision, data analysis, and effective presentation skills [ 54 ]. The survey also revealed knowledge deficits related to legislation and community engagement. The investigators concluded that effective targeting of these group training needs would require development of university-wide policies for training [ 54 ].

Organizational training needs analysis

Three articles focused on improving outcomes for an organization, such as a healthcare system, hospital, or business [ 27 , 36 , 47 ]. Targeted populations were nurses, physicians, other healthcare professionals, and business employees. Barratt and Fulop [ 27 ] applied the TNA tool to improve use of research, and knowledge generation participation, across healthcare and public health organizations in London and Southeast England. In doing so, the investigators identified key tasks, priorities, and barriers to building research capacity, such as assessing the relevance of research and learning about new developments [ 27 ]. An earlier study by Hicks and Hennessey explored the issue of evidence-based clinical care within the context of diminishing resources in the British NHS [ 36 ]. A TNA survey from seven NHS trusts showed common training needs and skill deficits in relevance to locality and clinical area. The authors concluded that targeting the real skill deficits of the workforce, as well as the personnel most in need of training, was essential for effective integration of evidence-based care within routine practice [ 36 ]. Last, Moty [ 47 ] focused on technology improvement at a contract research organization to incorporate user feedback into a portal system through the TNA tool. By incorporating end users’ input to optimize portal design, more positive opinions about portal technology could be solicited, and desire to use technology could be increased [ 47 ]. All three articles demonstrated the tool’s versatility in addressing organizational training needs at a systems level through an integrated approach.

This integrative review synthesized evidence about TNA tool utilization across the globe, and critically appraised its impact in CPD across various disciplines, settings, and countries. The tool proved to be modifiable for different purposes and contexts, without compromising its high validity and reliability. Its flexible design allowed it to be easily adapted to various populations, settings, and cultures while retaining its psychometric characteristics. Hence, the tool’s value as an international instrument for analyzing training needs in the healthcare and education sectors became evident.

TNA tool utilization across the globe

Following initial development and testing, the TNA instrument was successfully used in the UK to identify individual training needs and trends related to demographics, with an emphasis on development of the NP role at the early stages [ 12 , 13 , 30 ]. Carlisle and colleagues [ 8 ] summarized the latent factor structures that affect the occupational profile construct of the TNA scale and examined them within the Australian context. The investigators confirmed the original five-factor model and suggested that the underlying dimensions relating to the occupational profile were perceived to be important for high performance by nurses in Australia [ 8 ]. Nevertheless, the majority of studies reflecting individual training needs struggled with low response rates and self-report bias. Therefore, investigators cautioned about conclusions drawn from data that relied on individuals’ own perceptions of their learning needs. At the team/IP level, perception of training gaps and competences among nurses, midwives, physicians, and public health staff in settings ranging from hospitals to rural health facilities emerged throughout 10 countries. Specifically, in Singapore [ 26 ], Australia [ 28 ], Saint Lucia [ 29 ], Indonesia [ 31 ], UK [ 34 ], Greece [ 45 , 46 ], Tanzania [ 48 ], South Africa [ 51 ], India [ 52 ], and Sudan [ 54 ]. These studies used the TNA tool for primary data collection, with one translation and validation into Bahasa Indonesian language [ 31 ] and another into Greek [ 45 ]. Training needs of a group of interest were compared to those of other professional groups or team members to tailor CE offerings and optimize IP operations. At the organizational level, UK healthcare institutions and NHS trusts [ 27 , 36 ] as well as a US contract research organization [ 47 ] used the TNA instrument to improve research capacity/utilization, identify key barriers, and mitigate resistance to change. By establishing the relationship between organizational factors (hospitals) and demographic variables, individual occupational competency profiles, as well as team professional development, can be planned and executed by HR departments.

Further synthesis of sampled participating countries, depicted in Fig. 2 , revealed that two-thirds of the studies occurred in HICs and one-third in MICs, with only one study stemming from an LIC. Out of 11 studies that used translated TNA versions, three were from Indonesia (MIC), two from Greece (HIC), and one study involved six European countries (4 HICs, 2 MICs). Cross-country comparison by income classification and TNA theme allowed for examination of challenges or limitations in usage of the original, adapted, or translated TNA tool version, and how these were addressed by the investigators. According to Gaspard and Yang [ 29 ], how a healthcare professional determines which tasks are essential, and how they perceive their actual performance of that task, may be influenced by several factors. For instance, motivation for continuous learning, a special interest in a particular task, a specific education deficit, and satisfaction or not with unit management. This limitation is addressed by allowing for two ranking systems - where employers also rank employees - to cross-check motivation and establish the need. For example, to determine NP training that would satisfy NHS trust aims, a full training needs analysis of nurses and their immediate supervisors was carried out [ 34 ]. The nurses completed the analysis with their own perceptions of training needs, while their managers completed it on behalf of the identified nurse. The resulting mutually agreed training program enhanced understanding of both parties’ agendas and could be achieved with minimum conflict [ 8 , 33 , 34 , 46 ]. For Greek nurses in rural PHC settings, appropriate training activities, along with organizational changes, had potentially equal impact on short-term staff development and long-term strategic planning programs [ 46 ].

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Literature heat map – TNA tool use by country income level. *Income country classification by World Bank [ 23 ]

Reported flaws or limitations of the original or adapted/translated TNA tool included: a) small-scale study [ 8 , 26 , 37 , 40 , 42 , 45 , 46 ]; b) polling only one organization, or specific unit [ 26 , 29 , 37 , 42 , 49 ]; c) not surveying employers or stakeholders [ 28 , 29 , 48 , 51 ]; d) low participation or item completion rates [ 34 , 38 , 45 , 46 , 53 ]; e) lack of consensus at a national level regarding training content [ 45 ]; and f) focus on individual and team assessment, rather than organizational [ 25 , 39 ]. Last, one study included only 10 out of the 30 original TNA items, with the rest of items being newly introduced [ 50 ], which exceeds the developers’ threshold for psychometrics modification [ 14 ]. Furthermore, some investigators recommended further studies to explore TNA’s: a) applicability in a wider healthcare system, b) feasibility as a large-scale survey instrument in secondary and tertiary care settings, and c) usability for collaborative activities, especially through global information technology network teaching programs [ 34 , 45 , 48 ].

The main advantage of the TNA instrument is the accompanying detailed instruction manual, made available by the developers through the WHO Workforce Alliance website [ 14 ]. According to this manual, the standard 30-item questionnaire can be tailored to a particular study focus. Up to 8 of the original items can be changed or omitted, and up to 10 new items can be added. To this direction, the developers have included an example of how to adjust the questionnaire ([ 14 ], p.21-25). The additional items are to be devised according to an accepted psychometric process for developing questionnaires. For example, a literature review, focus group and interview with relevant personnel should be conducted, with the information distilled into themes, using an approved data-reduction method, such as the Thematic Network Analysis [ 55 ]. This provides the core areas from which tailored items are to be constructed. Coverage of the themes (and subsequent items) should be comprehensive and appropriate. These themes will form the basis for new items, which should be in a format similar to that of the standard questionnaire. Modified questionnaires should be piloted with a small sample. The manual includes additional item banks that have been used in other studies, grouped as follows: “Extended nursing role” , “Nurse prescribing” , “Specialist care”, “Child abuse / child protection”, and “Management” ([ 14 ], p.50-55). This item bank allows for easy tailoring to an investigator’s aim and unique context.

Global impact in continuous professional development

Regardless of country and profession surveyed, the tool consistently revealed the perceived and assumed training needs, clarified roles, and facilitated CPD at the individual or team level. Sampled literature revealed that there were no universal trends in training needs according to locus of practice, and that training requirements were specific to the actual role performed within an organizational environment. For example, Hicks & Tyler [ 38 ] and Hicks & Fide [ 39 ] demonstrated that a more targeted, less costly, training program would be optimum, upon surveying the roles and training needs of family planning nurses and breast care nurses in the UK. Organizational factors were shown to determine the occupational profile and training needs of nurses in primary and secondary care across Australia, UK, and the USA [ 8 , 30 , 36 ]. Similarly, most surveyed caregivers in five European countries declared a need for training in the psychosocial aspects of caregiving [ 50 ]. Yet, when dealing with stress, caregivers from Italy and Greece had lower needs than those from Poland, UK, and Turkey. Despite the socio-economic differences among countries, all participants faced increasing demands from caregiver burden [ 50 ]. For employees in the Nigerian health insurance industry, addressing the gaps through an on-the-job training course was deemed to be the optimum approach [ 25 ]. For each country seeking to minimize economic impact and streamline processes, the TNA tool provided an affordable, standardized approach to prioritize and implement an effective CPD program.

Several other studies concurred on the urgent need for flexible and tailored CPD, as an outcome of a comprehensive TNA analysis [ 26 , 33 , 40 , 44 , 46 , 52 – 54 ]. Especially in middle-income and low-income countries, such as Saint Lucia, South Africa and Sudan, strengthening university-level education for nurses and other healthcare professionals was a key recommendation for evidence-based decision making [ 29 , 51 , 54 ]. In the case of Indonesia, the introduction of TNA in a series of studies, carried out by Hennessy and colleagues [ 31 – 33 ], motivated several junior nurse researchers to pursue and study CPD, as reflected in multiple references of the instrument. Given the prevailing budget constraints and limited accessibility to research funds, it was not surprising that training needs in research competences emerged as top priorities across studies conducted in MICs and LICs. In Turkey, building research capacity among public health professionals to tackle prevailing non-communicable diseases, was seen as a national priority [ 42 ]. Following identification of several individual, team and organizational barriers, a comprehensive CPD plan for junior researchers, and a QI plan for governmental institutions were recommended. This latter plan provides a roadmap for addressing the lack of coordination between institutions and researchers, establishing research monitoring and evaluation, and strengthening routine health information systems. Similarly, in Sudan, the top QI priority for university faculty of Dentistry was research, followed by leadership, health professions management, community engagement, and teaching skills [ 54 ]. As demonstrated in a UK study, raising the ability of NHS organizations to use research and generate knowledge was tied to improved services and population health [ 27 ]. The above findings support the argument for research capacity as an essential component of PHC nursing [ 56 ]. Moreover, findings show the critical need for operational integration of standardized QI processes across units or institutions in order to close the gap between theory and practice [ 57 ]. Hence, implementation of a regionally based CPD and QI program, stemming from TNA application, could be the solution to a healthcare system in need of reform.

Strengths and limitations

Integrative reviews allow for the combination of diverse methodologies (i.e., experimental and non-experimental research) in order to more fully understand a phenomenon of concern [ 58 ]. By combining data from the theoretical as well as empirical literature, this review could potentially impact evidence-based practice for nursing and other healthcare professions. The ongoing worldwide interest in the Hennessy-Hicks TNA instrument and manual has been a strong incentive for this review. Following personal communication with the developers, they confirmed receipt of many email enquiries, estimated around 100, from around the world asking for permission or clarification about using the tool and informing about outcomes. Unfortunately, there is no cumulative record of requests during the past 25 years. This lack of usage data and repository was further compounded by inability to obtain webpage metrics (i.e. ‘hits’ and ‘downloads’) due to the hosting Global Health Workforce Alliance (GHWA) webpage no longer being maintained [ 14 ]. Therefore, no information was available on who has been using the tool nor who is resourcing the archived tool on the GHWA website.

This review was based on an extensive search of four major electronic databases and a targeted manual search of grey literature and cross-listed references. The selected databases (PubMed, CINAHL, Scopus, and Google Scholar) capture a variety of international journals in the nursing, social sciences, and biomedical literature, with relevant hand-searched theses and dissertations also included. All articles were independently reviewed and appraised, using an adapted hierarchy scale for level of evidence [ 26 , 27 ]. The main limitation stems from the exclusion of any relevant literature published in languages other than English. According to the developers, TNA has been translated into many other languages, including Arabic and Chinese, but there was scarce evidence published in the English literature. Upon appraisal, variation in criteria application, along with cross-country cultural and linguistic variations are also acknowledged. Last, World Bank rankings [ 23 ] were based on the 2020 index rather than the year when the study was conducted. Because of the relatively small sample size ( n = 33), the investigators combined the “low-middle income countries” with the “upper-middle income countries” categories under “middle-income countries” (MIC).

Implications

The TNA instrument allows for triangulation of a) assessment (identifying and triaging needs); b) needs (gap between what exists and what is required); and c) training (acquiring knowledge, skills or change attitude). Our literature review synthesized the reported use and value of the Hennessey-Hicks TNA tool across settings, populations, and countries, identified the enablers and barriers to its use, and distilled best practice CPD recommendations. Viewed from the KTA Framework perspective, our findings explain how the scholarship of discovery (TNA tool development, psychometrics of adapted or translated versions) leads to the scholarship of integration (translation and cultural adaptation of TNA), and ultimately to scholarship of application (using different versions of the tool across various settings, populations, or countries). As knowledge moves through each stage, it becomes more synthesized and therefore, useful to end-users. Hence, for healthcare professionals, CE should be based on the best available knowledge, the use of effective educational strategies, and the planned action theories to understand and influence change in practice settings [ 17 ]. A recent metasynthesis of CPD literature highlights nurses’ belief in CPD, as fundamental to professionalism and lifelong learning, and its importance in improving patient care standards [ 59 ]. Yet, it shows a disconnect between nurses’ CPD needs and expectations with the organizations’ approaches to professional development. The authors conclude that access to CPD should be made more attainable, realistic and relevant [ 59 ]. By translating TNA evidence into action, health policy makers, administrators, and educators can effectively design appropriate, cost-effective CPD programs with clear priorities to achieve the desirable knowledge, skills and practice, tailored to local needs.

There is also a high level of fit between the adopted KTA Framework and the affiliated WHOCC’s Terms of Reference. Completion of this review coincided with the start of a project by the Registered Nurses Association of Ontario, aiming to develop a repository of measurement tools that can be mapped to the KTA Framework, and to report on their pragmatic and psychometric properties. Given that the TNA measurement tool has been identified as mappable to the KTA framework, the potential synergy between the two groups is promising. Moreover, our findings are aligned with WHO recommendations based on the “Framework for Action on Interprofessional Education and Collaborative Practice” [ 24 ]. These call for health policy makers to systematically address training needs of the healthcare workforce in order to strengthen IPE and collaborative practice. As tasked by the Pan American Health Organization (PAHO), the affiliated WHOCC aims to enhance the use and dissemination of knowledge resources that build capacity and leadership for nurse and midwife educators. Hence, lessons learned will be used to promote TNA tool application and integration for individual, team/IPE, and organizational improvement across the PAHO region (North/Central/South America and the Caribbean). These steps are both timely and relevant for evaluating training and competency, and for regulating nursing practice in the Americas [ 15 ] during the post-pandemic era.

Since its development in 1996, the TNA instrument has been widely used as a clinical practice and educational quality improvement tool across continents. Translation, cultural adaptation, and psychometric testing within a variety of settings, populations, and countries consistently reveal training gaps along the individual, team/interprofessional, and organizational themes. It is not only applied to identify training needs and demographic trends, but also to prioritize targeted training strategies and CPD programs. Furthermore, it facilitates triaging and allocating limited educational resources, especially in low and middle-income countries. These findings underscore the tool’s effectiveness in addressing the “know-do” gap in global human resources for health by translating knowledge into action.

Acknowledgements

We would like to thank the TNA tool developers, Drs. Deborah Hennessy and Carolyn Hicks, for their input, unwavering support, and strong commitment to sharing their knowledge and expertise with the international community. Also, our appreciation to Dr. Silvia Cassiani, PAHO Regional Officer; Dr. Erica Wheeler, PAHO representative; and the WHO Health Workforce Department representatives for providing helpful background information and connection with stakeholders.

Abbreviations

Authors’ contributions.

AM; concept design, synthesis and interpretation of data, drafting and revision of manuscript. SM; data extraction, appraisal and synthesis, drafting of manuscript. RB; literature search, drafting of manuscript. LT; data extraction and synthesis, drafting of manuscript. All authors reviewed and approved the final manuscript.

Not applicable.

Availability of data and materials

Declarations.

Not applicable (non-human subjects – review study).

The authors declare no competing interests.

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Adelais Markaki, Email: ude.bau@ikakram .

Shreya Malhotra, Email: ude.drofnats@amayerhs .

Rebecca Billings, Email: ude.bau@bracceb .

Lisa Theus, Email: ude.bau@lsueht .

Open access
Published: 31 May 2021

Training needs assessment: tool utilization and global impact

Adelais Markaki 1 , 2 ,
Shreya Malhotra ORCID: orcid.org/0000-0002-8708-5451 3 ,
Rebecca Billings ORCID: orcid.org/0000-0001-5203-7217 2 &
Lisa Theus ORCID: orcid.org/0000-0001-8886-8768 1 , 2

BMC Medical Education volume 21 , Article number: 310 ( 2021 ) Cite this article

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Acknowledging the above challenges and limitations, investigators from the United Kingdom (UK) in 1996 initiated efforts towards a cost-effective and psychometrically sound TNA tool for the healthcare industry. The Hennessy-Hicks Training Needs Analysis (TNA) Questionnaire, referred as “TNA” from here on after, was developed to identify individual training needs, organizational requirements, and targeted training strategies [ 10 , 11 ]. Since its development, the TNA tool has been psychometrically tested and used for a variety of purposes among several settings and populations. It has a proven track record for use with primary healthcare teams, district and practice nurses, nurse practitioners (NPs), and health visitors in the UK [ 10 , 11 , 12 , 13 ]. The TNA has been shown to minimize response bias and provide reliable information about current performance levels, skill areas most in need of further development, and how to best achieve optimal results. This knowledge facilitates organizations with priority-setting and policy development, as well as with evaluation of their continuous professional development (CPD) programs.

Search strategy – eligibility criteria

PRISMA Search Strategy for TNA Tool

Data extraction and quality appraisal

In terms of TNA tool use, 4 (12.1%) studies used the original English version instrument, 23 (69.7%) adapted the English version, and 6 (18.2%) translated and culturally adapted the tool. Translation and cultural adaptation of the original TNA was carried out in the following languages/countries: a) Bahasa Indonesian - tested among community nurses and midwives in Indonesia [ 31 , 32 , 33 ]; b) Greek - tested among rural primary care nurses, midwives, and health visitors in Greece [ 45 , 46 ]. In addition, a modified version of TNA was translated and culturally adapted into the following languages/countries: a) Kiswahili – tested among reproductive, maternal, and newborn healthcare workers in Mwanza, Tanzania [ 48 ]; b) Bulgarian, Polish, Italian, Albanian, and Romanian – tested among formal and informal caregivers across European Union countries and immigrant communities [ 50 ]. Furthermore, a thematic analysis revealed the following three levels in training needs analysis: a) individual level; b) interprofessional or team/unit level; and c) organizational level.

Individual training needs analysis

As listed in Table 1 , a total of 17 studies centered on identifying or targeting needs at the individual level within a specific population of interest across a variety of settings [ 8 , 12 , 13 , 25 , 30 , 32 , 33 , 37 , 38 , 39 , 41 , 42 , 43 , 44 , 49 , 50 , 53 ]. Nurses, physicians, midwives, and other healthcare professionals were studied in primary healthcare, acute care, healthcare organizations, and other businesses. All 17 articles applied the TNA tool to determine specific job roles and responsibilities within the targeted setting. Hence, an individual’s perceptions about which tasks were most important for performing their jobs were assessed and captured in column A of the TNA tool. For example, Hicks and Tyler [ 38 ] used the tool to determine the required education for family planning nurses in the UK, analyzing the tasks these nurses performed, while also allowing them to indicate their training needs. By comparing the roles of the family planning nurse with the family planning nurse prescriber, the investigators determined the nuances that distinguished the two roles in two consecutive studies [ 38 , 53 ].

Team/Interprofessional training needs analysis

Organizational training needs analysis

TNA tool utilization across the globe

Literature heat map – TNA tool use by country income level. *Income country classification by World Bank [ 23 ]

Global impact in continuous professional development

Several other studies concurred on the urgent need for flexible and tailored CPD, as an outcome of a comprehensive TNA analysis [ 26 , 33 , 40 , 44 , 46 , 52 , 53 , 54 ]. Especially in middle-income and low-income countries, such as Saint Lucia, South Africa and Sudan, strengthening university-level education for nurses and other healthcare professionals was a key recommendation for evidence-based decision making [ 29 , 51 , 54 ]. In the case of Indonesia, the introduction of TNA in a series of studies, carried out by Hennessy and colleagues [ 31 , 32 , 33 ], motivated several junior nurse researchers to pursue and study CPD, as reflected in multiple references of the instrument. Given the prevailing budget constraints and limited accessibility to research funds, it was not surprising that training needs in research competences emerged as top priorities across studies conducted in MICs and LICs. In Turkey, building research capacity among public health professionals to tackle prevailing non-communicable diseases, was seen as a national priority [ 42 ]. Following identification of several individual, team and organizational barriers, a comprehensive CPD plan for junior researchers, and a QI plan for governmental institutions were recommended. This latter plan provides a roadmap for addressing the lack of coordination between institutions and researchers, establishing research monitoring and evaluation, and strengthening routine health information systems. Similarly, in Sudan, the top QI priority for university faculty of Dentistry was research, followed by leadership, health professions management, community engagement, and teaching skills [ 54 ]. As demonstrated in a UK study, raising the ability of NHS organizations to use research and generate knowledge was tied to improved services and population health [ 27 ]. The above findings support the argument for research capacity as an essential component of PHC nursing [ 56 ]. Moreover, findings show the critical need for operational integration of standardized QI processes across units or institutions in order to close the gap between theory and practice [ 57 ]. Hence, implementation of a regionally based CPD and QI program, stemming from TNA application, could be the solution to a healthcare system in need of reform.

Strengths and limitations

Implications

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

Continuing Education

Continuous Professional Development

High Income Countries

Interprofessional

Inter-Professional Education

Knowledge to Action

Low Income Countries

Middle Income Countries

National Health System

Nurse Practitioner

Primary Health Care

Quality Improvement

Pan American Health Organization

Training Needs Analysis

World Health Organization

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Markaki, A., Malhotra, S., Billings, R. et al. Training needs assessment: tool utilization and global impact. BMC Med Educ 21 , 310 (2021). https://doi.org/10.1186/s12909-021-02748-y

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Training needs assessment
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Continuous professional development
Quality improvement
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research paper on training need analysis

The Current State of Research on Training Effectiveness

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Thomas N. Garavan 11 ,
Fergal O’Brien 12 ,
James Duggan 13 ,
Claire Gubbins 14 ,
Yanqing Lai 15 ,
Ronan Carbery 16 ,
Sinead Heneghan 17 ,
Ronnie Lannon 18 ,
Maura Sheehan 19 &
Kirsteen Grant 20

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This chapter addresses the current state of research on training effectiveness in organisations. It summarises the key findings on what we know about training effectiveness, the research emphasis given to different components of the model, and how research informs the ways in which organisations should approach learning and development to maximise effectiveness. The chapter highlights the role of training needs analysis, the types of attendance policies that should be used, the most effective design of training delivery to maximise effectiveness, the relative effectiveness of training methods, the organisation of training content, the importance of learning or training transfer, and the types of outcomes that are derived from learning and development.

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Garavan, T.N. et al. (2020). The Current State of Research on Training Effectiveness. In: Learning and Development Effectiveness in Organisations. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-48900-7_5

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This paper is in the following e-collection/theme issue:

Published on 26.4.2024 in Vol 26 (2024)

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

Authors of this article:

Original Paper

Natalie Benda 1 , PhD ;
Sydney Woode 2 , BSc ;
Stephanie Niño de Rivera 1 , BS ;
Robin B Kalish 3 , MD ;
Laura E Riley 3 , MD ;
Alison Hermann 4 , MD ;
Ruth Masterson Creber 1 , MSc, PhD, RN ;
Eric Costa Pimentel 5 , MS ;
Jessica S Ancker 6 , MPH, PhD

1 School of Nursing, Columbia University, New York, NY, United States

2 Department of Radiology, Early Lung and Cardiac Action Program, The Mount Sinai Health System, New York, NY, United States

3 Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, United States

4 Department of Psychiatry, Weill Cornell Medicine, New York, NY, United States

5 Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States

6 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States

Corresponding Author:

Natalie Benda, PhD

School of Nursing

Columbia University

560 West 168th Street

New York, NY, 10032

United States

Phone: 1 212 305 9547

Email: [email protected]

Background: Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms.

Objective: We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings.

Methods: We conducted semistructured interviews with 36 participants—15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process.

Results: Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems–level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured.

Conclusions: Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

Introduction

This study focused on designing a culturally congruent mobile health (mHealth) app to support postpartum symptom monitoring, as the current practice does not adequately support patients in identifying the warning signs of pregnancy-related death (PRD). First, we describe the public health case for symptom monitoring and decision support for PRD, specifically among US-based, Black patients, a group that faces severe disparities [ 1 , 2 ]. Next, we discuss why the current mechanisms for symptom monitoring and decision support are insufficient. We then outline the existing solutions while also emphasizing the need for new interventions, particularly why those using a combination of mHealth and patient-reported outcomes (PROs) may be appropriate. Finally, we introduce a conceptual model used to accomplish our study objectives.

PRD and Associated Health Disparities

The pregnancy-related mortality ratio has increased by >200% in the United States in the past 2 decades, and in a recent review of PRDs, experts estimated that 80% of the deaths were preventable [ 3 ]. The Centers for Disease Control and Prevention (CDC) defines PRD as “the death of a woman while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy” [ 4 , 5 ]. Mental health conditions (22.7%), hemorrhage (13.7%), cardiac and coronary conditions (12.8%), infection (9.2%), thrombotic embolism (8.7%), and cardiomyopathy (8.5%) have been cited as the most common causes for PRD [ 3 ]. Although the global maternal mortality rate has declined, the global rates are still high with 287,000 people dying following childbirth in 2020. There are significant disparities in maternal mortality based on a country’s income, with almost 95% of the cases occurring in low- and middle-income countries [ 6 ]. Stark disparities in pregnancy-related outcomes in the United States, such as PRD, exist based on race. Specifically, Black or African American (henceforth, referred to as “Black”) perinatal patients experience PRD 3 times more than White perinatal patients [ 1 , 2 , 7 - 10 ].

The disparities in maternal health outcomes experienced by Black patients in the United States are based on inequitable access to care, biased treatment, and inadequate communication, driven by systemic racism and all the cascading effects it creates. Black perinatal patients are significantly more likely to be uninsured and significantly less likely to have a usual source of medical care (eg, a primary care clinician) than White patients [ 7 , 10 ]. When Black patients seek care, they face implicit biases that negatively affect care quality and health outcomes [ 1 , 7 , 10 - 12 ]. Unsurprisingly, these biases have led to reduced trust in the health care system among Black patients [ 13 - 17 ]. Black patients also receive less patient-centered communication and feel that they have poorer access to communication with their medical team [ 10 , 18 , 19 ]. Our study aimed to improve the patient centeredness of information and support for Black patients in the postpartum period through a participatory design, an approach by which representative end users are involved throughout the design process [ 20 - 23 ]. While this study focused on Black postpartum patients in the United States, we believe that our findings may provide insights for improving perinatal support for patients from minority groups globally.

Challenges to Supporting Symptom Recognition and Treatment Seeking Post Partum

Patients encounter several challenges recognizing concerning postpartum symptoms. First, the initial postpartum visit occurs 6 weeks after birth, and 86% of PRD cases occur within the first 6 weeks post partum [ 24 , 25 ]. Second, most strategies for improving postpartum outcomes focus on hospital-based solutions, which rely on people recognizing symptoms and contacting a health professional [ 7 ]. Most counseling regarding the warning signs of PRD occurs during the discharge process following delivery, when people are physically exhausted from childbirth and primarily focused on infant care [ 24 ]. As such, this is a suboptimal time for patient education about postpartum risk factors. Discharge nurses report spending <10 minutes on the warning signs of postpartum issues, and most nurses could not correctly identify the leading causes of PRD, making it unlikely that their patients could recognize the warning signs [ 26 ]. There are many measures for postpartum symptom reporting, but the most common instruments focus narrowly on specific mental health issues, many of which are not specific to postpartum mental health or postpartum health–related quality of life [ 27 ]. While these are helpful measures to use in a clinic or hospital setting, they do not provide real-time decision support regarding the full spectrum of severe symptoms that may be indicative of PRD.

Suitability of Different Solutions for Supporting Symptom Monitoring

mHealth can address the need for tailored, dynamic symptom monitoring and support. The Association of Women’s Health, Obstetric, and Neonatal Nurses and the CDC have developed 1-page summaries to help patients identify the warning signs of PRD, such as the Urgent Maternal Warning Signs (UWS) [ 28 , 29 ]. These tools represent a positive step toward improving symptom management, but these solutions do not provide real-time, tailored support. Telephone-based support staffed by health professionals has been demonstrated to decrease postpartum depression and improve maternal self-efficacy [ 30 - 33 ]. However, 24-hour hotlines can be resource intensive, and people may still experience bias when accessing these services. The goal of this study was to conduct a qualitative needs assessment for the Maternal Outcome Monitoring and Support app, an mHealth system using PROs to provide decision support for postpartum symptom monitoring.

Mobile phones offer a viable, inclusive option for intervention delivery for Black people of childbearing age. In 2020, data from the Pew Research Center indicate that 83% of Black people owned smartphones, which is comparable to smartphone ownership among White people (85%). Smartphone ownership is also higher among people aged <50 years (96%), which encompasses most postpartum patients [ 34 ]. However, Black people are twice as likely as White people to be dependent on smartphones for internet access [ 35 ]. mHealth-based apps for blood pressure and weight tracking during pregnancy have demonstrated success among diverse groups, providing evidence that mHealth may be an acceptable means for symptom reporting in the target population [ 36 - 38 ].

Symptom education and PRO-based interventions have demonstrated success in improving knowledge, self-efficacy, and outcomes. Use of PROs has improved symptom knowledge, health awareness, communication with health care professionals, and prioritization of symptoms in patients with chronic disease and cancer [ 39 - 44 ]. Multiple studies have also demonstrated that educational interventions regarding expected symptoms in the postpartum period can improve self-efficacy, resourcefulness, breastfeeding practices, and mental health [ 12 , 38 , 45 - 47 ]. However, given the issues related to trust and disparities in patient-centered communication, it is critical to understand Black patients’ perspectives about how such a system should be designed and implemented.

Conceptual Model

To study the issue of supporting symptom monitoring, we combined 2 theoretical frameworks ( Figure 1 ): the common sense model of self-regulation (health behavior) by Diefenbach and Leventhal [ 48 ] and the model of human information processing (human factors engineering) by Wickens [ 49 ]. The model by Diefenbach and Leventhal [ 48 ] depicts patients as active problem solvers with a mental model of their conditions. Patients process their symptoms, both cognitively and emotionally, and then evaluate whether action is needed [ 48 ]. The patient’s mental model of their condition, personal experiences, and sociocultural factors impact processing, evaluation, and action. In the information processing model by Wickens [ 49 ], action occurs in 2 steps—selection and execution [ 48 ]. Environmental or organizational factors also affect patients’ selection of actions and whether they can execute an action. For example, a patient may suspect that they should visit the emergency room but may not go because they do not have insurance, transportation, or childcare. Our qualitative inquiry investigated how to better support symptom processing and appropriate response selection, while also uncovering the barriers to action that may need to be mitigated.

The goal of this study was to identify the design and implementation needs of an mHealth-based symptom self-monitoring and decision-support system to support Black patients in determining when to seek care from a health professional for signs of PRD in the postpartum period. This tool will support both somatic and psychological symptoms given their complex, critical, and connected presentation. We used the described conceptual model in qualitative inquiry and pragmatic intervention design to provide contributions regarding the following: (1) relevant symptom inputs for postpartum support, (2) drivers that may affect symptom processing, and (3) how the previous 2 aspects highlight the design needs for symptom self-monitoring and patient decision support. To address our study objective, we conducted semistructured interviews with postpartum Black patients, obstetrics health professionals, and mental health professionals.

The study was conducted in 3 tertiary care hospitals and affiliated clinics within the same health system in New York City. The 3 hospitals, taken together, are involved in the delivery of >14,000 babies annually. All participants were either patients who received obstetric care in the included sites or health professionals affiliated with the sites.

Eligible patients were identified by the institutions’ research informatics team using electronic health record data. First, the patients’ providers consented to their patients being contacted, and patients’ charts were reviewed by the primary obstetrician or designate to ensure that the patient was eligible for the study and that they had a delivery experience that would allow them to participate in the interview without undue stress. Next, the patients were sent an invitation to participate via the email address listed in their record. We also posted fliers in 2 high-risk, outpatient obstetric clinics.

Obstetric and mental health professionals were eligible if they were affiliated with one of the institutions in the obstetrics or mental health department. Brief presentations were given at relevant faculty meetings, and participants were contacted individually via email or through departmental listserves.

Interested participants from all groups used a link to schedule a time to speak with a researcher.

Ethical Considerations

The study was approved by the affiliated medical schools’ institutional review board (protocol number 20-08022582). All participants provided written informed consent. Study data were coded (ie, all identifying information was removed) to protect participant privacy. Each participant was compensated US $50 for their time via a physical or electronic gift card.

Study Design and Sample

The study used semistructured interviews with 3 key stakeholder groups: recent postpartum Black patients, obstetric health professionals, and mental health professionals. Eligible patients were within 12 months post partum of a live birth, self-identified their race as Black or African American, and had at least 1 somatic or psychological high-risk feature associated with their pregnancy. High-risk features included attendance at a high-risk clinic for prenatal or postnatal care, inpatient hospitalization within 12 months post partum, a prescription of an antidepressant or benzodiazepine within 12 months of the pregnancy, or a new diagnosis of depression or anxiety within 12 months of the pregnancy. High-risk clinics treated various conditions, but the most common conditions were gestational hypertension and gestational diabetes.

We adopted an interpretivist qualitative research paradigm to study patient and health professionals’ perspectives of how symptom recognition and care seeking may be better supported [ 50 ]. Our methodological orientation involved directed content analysis, adopting an abductive reasoning approach. First, we used the previously specified conceptual model to construct questions and thematically categorize responses [ 48 ]. Then, we allowed unique subthemes to inductively emerge from the data collected [ 51 ].

Interview Guide Development

Interview guides were iteratively developed by our team of researchers with expertise in obstetrics, perinatal mental health, nursing, consumer informatics, inclusive design, and qualitative methods. The guide for each stakeholder group was reviewed and piloted before enrollment of the first participant. Interview guides were tailored for patients or health professionals but followed a similar structure, based on our conceptual model ( Figure 1 ), such that participants were first asked about barriers to and facilitators of processing symptoms cognitively and emotionally (eg, Do they notice the symptom or realize its severity?), making decisions about symptoms they are experiencing (ie, When to seek help from a health professional?), and taking action on problematic symptoms. Probing questions encouraged participants to elaborate on experiential, educational, sociocultural, organizational, environmental, or health systems–level drivers of patients’ symptom management. Then, participants were asked a series of questions related to their thoughts regarding the design of the mHealth system, including how to best report symptoms, the wording of system decision support, the desired level of involvement of the obstetrics health professionals, the means for facilitating outreach to a health professional, additional information resources, and preferences for sharing information included in the system with a trusted friend or family members. During this process, obstetrics and mental health professionals were also shown a handout that outlined the draft of the symptom management algorithm for the system being developed (CDC’s UWS) and asked if they would make any changes, additions, or deletions [ 29 ]. Full interview guides are included in Multimedia Appendix 1 .

Data Collection

All interviewees provided consent electronically before the interview. A PhD-trained qualitative research expert (NB) completing a postdoctoral study in health informatics and population health conducted all the interviews via Zoom (Zoom Video Communications) or telephone. Participants had the option to request an in-person interview, but none of them chose this option. Interviews lasted 30 to 60 minutes and were audio recorded. We explicitly described the study objectives to each participant before the interview. Following the interview, participants completed a demographics survey electronically. All electronic survey information was collected using REDCap (Research Electronic Data Capture; Vanderbilt University).

Data Preparation and Analysis

Audio recordings were converted into transcripts using an electronic software (NVivo Transcription; QSR International) and manually checked for accuracy by a study team member who did not conduct the initial interviews. We completed all data analyses using NVivo (versions 12 and 13), but we manually analyzed the data and did not use computer-aided techniques (eg, computerized emotion detection or autocoding).

Data were analyzed using thematic analysis and the constant comparative process [ 51 - 53 ]. Specifically, each analyst open coded the transcripts, by coding segments that pertained to the research questions, as opposed to coding all words and phrases. We used thematic analysis to detect the common and divergent needs for postpartum symptom monitoring. We chose this method over other approaches such as grounded theory or sentiment analysis because our needs were pragmatic to solution design, and we were not attempting to establish theory, describe phenomena, or represent collective feeling about a topic.

The first deductive analysis was conducted using an initial theoretical model derived from the common sense model by Diefenbach and Leventhal [ 48 ] and the model of human information processing by Wickens [ 49 ] ( Figure 1 ). To promote reliability, 2 coders in addition to the interviewer were involved in the analysis, and each transcript was first analyzed independently by at least 2 people (NB, SW, or SNdR), followed by meetings to resolve discrepancies based on consensus coding. The analysis team created initial codes based on the conceptual model and added new items to the codebook inductively (ie, post hoc instead of a priori, as they arose in the data). The team used NVivo to maintain a working codebook of themes, definitions, and relevant quotes derived from the data. The codebook was periodically presented to coinvestigators with expertise in obstetrics and perinatal psychiatry to improve external validity [ 51 , 52 ]. The sufficiency of sample size was assessed according to the theoretical saturation of themes encountered, specifically based on the need to add additional subthemes to the codebook [ 54 , 55 ]. After all the transcripts had been coded, at least 2 members of the coding team reviewed the data code by code to ensure that meaning remained consistent throughout the analysis and to derive key emerging themes [ 51 ].

Participant Characteristics

This study included 36 participants—15 (42%) obstetrics health professionals, 10 (28%) mental health professionals, and 11 (31%) recent postpartum Black patients. Table 1 presents the self-reported demographic information. As shown, 19% (7/36) of the health professionals and 11% (4/36) of the patients had missing data (ie, did not complete the questionnaire). Participants could also selectively choose not to answer questions. “Other” affiliations were possible for health professionals because those who had a secondary affiliation with one of the included sites but primary affiliation with another organization were eligible.

a N/A: not applicable.

b Health professionals’ self-reported role of resident psychiatrist, chief resident in psychiatry, psychologist, and patient care director was combined into the other category for analysis purposes.

Structure of Themes

Our initial theoretical model, derived from the common sense model by Diefenbach and Leventhal [ 48 ] and the model of human information processing by Wickens [ 49 ] ( Figure 1 ), described that patients experience some inputs (psychological and somatic symptoms of PRD). Then, there is a series of drivers that affect how patients cognitively and emotionally process (eg, notice and realize symptom severity), make decisions about, and act on symptoms they are experiencing. The nature of these symptoms, how they are processed, how decisions are made, and how they are acted upon then drive a conversation regarding the design needs for symptom monitoring and decision support for PRD. The emerging themes were organized into the following categories: (1) symptoms of PRD; (2) drivers of processing, decision-making, and action; and (3) design needs for a symptom-reporting and decision-support system. Quotes are labeled with study-specific identifiers: OB denotes obstetric health professional, MHP denotes mental health professional, and PT denotes patient.

Inputs: Psychological and Somatic Symptoms of PRD

Concerning and routine symptoms were reported both from a psychological and somatic perspective. Sometimes, the distinction between routine and concerning symptoms was clear. Other times, it was more challenging to differentiate routine versus concerning symptoms particularly because they were related to psychological health. Mental health professionals also noted the challenge that routine symptoms can progress to something more serious over time:

In my mind, like normal becomes abnormal, when there is any kind of functioning [loss] that like withstands two to three weeks. [MHP 04]

We really hear a lot about postpartum depression and stuff...A lot of women think...postpartum depression is you just don’t want to. You don’t have it. You go into depression where you can’t take care of your child and you don’t want to hold your child. You don’t feel connected to your child. And I learned...it can be so many different things. [PT 09]

A clear distinction was not always present between psychological and somatic symptoms:

If someone...has pain in their chest or shortness of breath, the first thing you want to think about is it sort of like clots and other kind of physiologic reasons for that. Those are also very implicated and sort of obviously [associated with] panic attacks and anxiety. So, I think though those symptoms are also relevant of physical symptoms, [they] are also relevant for mental health. [MHP 05]

Drivers of Processing, Decision-Making, and Action Based on the Symptoms Experienced

Several drivers were reported to affect symptom processing (ie, whether they noticed the symptom and its severity), patients’ capacity to decide what should be done (ie, make decisions), and whether they were able to act on concerning symptoms ( Table 2 ).

Table 2 presents exemplary quotes for emerging themes under a single driver, but many quotes were coded under multiple drivers in our analysis process. The following passage, for example, highlights how self-perception, sociocultural concerns, and the health system can overlap to present a complex set of factors that may prevent women from receiving the care they need for the symptoms they are experiencing:

A lot of times I think that does get overlooked because people feel like, well, you’re OK, you’re fine. But what research shows us is that especially for Black women, it really doesn’t matter how much money you make or your income level, like our postpartum and perinatal health outcomes are the same across the board, which is really detrimental. So, yeah, I think they get overlooked because of that. I think they get overlooked or we get overlooked in the health care system. But I also think we get overlooked by our family and friends because we’re the strong ones. So, if anybody can deal with this, it’s you. [MHP 10]

a MHP: mental health professional.

b PT: patient.

c OB: obstetric health professional.

Design Needs for a Symptom-Reporting and Decision-Support System

Obstetric health professionals, mental health professionals, and patients discussed multiple needs for improved PRD symptom reporting and decision support. The key design requirements are embedded and italicized in the following text.

Participants generally agreed that although the proposed system focuses on postpartum symptoms, it would be advantageous to introduce the system during pregnancy, particularly in the third trimester :

You have to reach women before they give birth. They might look, they might not look, they might look at it and be concerned. But then they might forget about it and not have time to call. Those first six weeks are really chaotic. [MHP 06]

I think in the third trimester would be great because often we don’t really have anything to talk about in the office. It’s very quick visits like blood pressure and you’re still pregnant and we’re just waiting. And so, I think and they start to have a lot of questions about like, well, when I get home and how’s this going to go? So, I think that time is a good time. We’re all kind of just waiting for labor to happen or full term to get there, and this kind of gives them something to feel like they can prepare for. [OB 08]

Patients were open to reminders regarding entering symptoms they were experiencing, and participants described a desire for just-in-time symptom reporting and decision support, so that they could get quick feedback as they were experiencing the symptoms:

When people get home so much in their life has changed. And it’s probably a very hectic time. So maybe I think that’s a great idea reaching out again, either a few days or a week later to make sure they’re really able to use it and engage with it to the extent that’s helpful to them. [OB 02]

I think it would be a good idea to have like a system where you can report whenever you want. [PT 03]

I think for me, I would say in the moment. But then also having something at the end of every week to just, you know, to check in with yourself. I think that would be good as well. [PT 09]

In addition to considerations about how symptoms would be recorded, participants stressed the importance of the wording of the decision-support messages that patients receive . For messages that inform the patient that their symptom did not seem to require immediate medical attention, it was important to ensure that the patient still felt heard and that they did not leave the interaction feeling stuck with nothing to do regarding a symptom that was concerning to them:

Reframe the message. You know...we apologize that you were experiencing this. We just want to reassure you that this is normal. [PT 01]

[You] don’t want to make anyone feel like their feelings aren’t valid because that’s a horrible thing, especially in health care, especially if a person is convinced that something is wrong with them and you’re telling them that it’s normal and is perfectly fine. So, in that situation, I would just, depending on what the issue is, I would also share information of what to look out for. [PT 05]

The first thing is that it’s normal, but also something that you want to be able to do for comfort. For me, I don’t have to do too much, especially if I’m having anxiety, like if I get a text back that says here are some things you can do in this very moment to handle it. And then also, here are some links or information that you can also look up. [PT 09]

In the events where a concerning symptom was reported and it was recommended that the patient should reach out to a health professional, importance of conveying a sense of urgency without scaring the patient:

You don’t want to scare people, but it’s kind of hard to get around that when something is serious, and you don’t want to dumb it down. [PT 01]

Participants wanted multiple, easy-to-do methods for connecting with their health professional team, including having the number to call pop up, scheduling a time for someone to call them, and being able to start a live web-based chat:

I like all the options, especially that form or chat you can have like, you know, those online chat where like you really chatting with someone for those who like the type. I’m the type of person I just want to make a phone call, right? So, like for me, [it] will be a call. Maybe say maybe if it’s five, five or ten minutes then that will be great. Like especially, it’s going to make me feel like, OK, there’s someone out there that will care about my health. [PT 06]

However, participants noted that they would prefer not to use a symptom-reporting and decision-support tool, but instead reach out directly via phone if they were experiencing issues.

Participants, particularly mental health professionals, described a need for improved nuance or details regarding the different psychological symptoms patients could experience that are indicative of severe mental health issues:

Thoughts of hurting yourself or someone else is a good one...I would say I would add difficulty bonding. It would add something about not being able to sleep, even if you could sleep, you know, like or your anxiety that doesn’t go away, that changes your behavior. So, it changes the way that you interact with the baby or kind of do childcare. I guess I would want to say something about. psychotic thoughts, like fear that someone else may be hurting you or...recurrent worries or anxieties that don’t go away. [MHP 02]

Patients had differing opinions regarding whether the system should be integrated with other health technologies, particularly the patient portal:

I love the patient portal. I was able to be traveling to reach out to my OB, to reach out to all, you know, the nurses and stuff like that and just experience things that I needed. [PT 09]

I feel like...it’s an integral part of my medical history. So, even if it may seem somewhat insignificant for whatever reason, I would still want to have access. [PT 09]

I didn’t find it [the patient portal] very helpful... [PT 03]

On the basis of the feedback from health professionals that it may be challenging for postpartum patients to process and recognize certain symptoms, especially those related to mental health, we explored whether patient participants would be open to sharing educational information about symptoms to expect (rather than sharing the actual symptom reports) with trusted friends or family members. Similar to other design considerations, results were mixed, but it seemed helpful to have a patient-driven option for sharing symptom-related educational information with chosen friends or family members :

I think that there’s so much going on it would help to have someone with a different perspective equipped with this information. [PT 02]

There’s a lot of shame that comes with this. I’m not sure people would actually want other people to know. I can’t speak for the majority, but I didn’t really want people to know because I don’t want the kind of energy that came with people knowing. [PT 05]

We also discovered the competing needs of balancing the patient’s desire for their health professionals to be involved in symptom reporting with the need to avoid significant increases to health professional workload :

I sort of wonder from the health care provider perspective, how involved is the provider in that in the app? Like, do they get like a PDF of all the information? Is that more work for the provider? How does the provider interpret that data? [MHP 03]

I feel like they [the health professional] should be super involved. Especially because I’m not just going off of my experience because, you know, I don’t want to feel like they’re not really like I’m experiencing. And so, it’s scaring me. So, I just want to know that, you know, you’re hands on with everything. [PT 01]

Finally, the participants desired information beyond PRD symptoms to entice them to use the system . They were supportive of including various types of information, such as breastfeeding support resources, milestones and information regarding their child, other websites and apps with trusted maternal and child health information, further support resources for how they feel mentally, and links to social services (eg, food, housing, or other assistance).

Principal Findings

In this qualitative study, we interviewed obstetric health professionals, mental health professionals, and Black postpartum patients. Our findings helped to identify the design and implementation needs of an mHealth-based, symptom self-monitoring and decision-support system designed to support Black patients in determining when to seek care from a health professional for signs of PRD in the postpartum period. We encountered important findings related to (1) inputs, including psychological and somatic symptoms; (2) drivers of processing, decision-making, and action based on the symptoms experienced; and (3) design needs for a symptom-reporting and decision-support system. We have discussed how our findings may be helpful to other postpartum populations as well as the implications of our study for patient decision-support in other clinical settings.

First, our findings related to symptom inputs revealed the challenges caused by the overlapping presentation of somatic and psychological symptoms. This provides support for our approach of including psychological and somatic issues in a single app, particularly given that mental health conditions are a leading cause of PRD. A 2021 review found 15 PRO measures for assessing postpartum recovery. The measures typically focused on mental health or health-related quality of life, but few included both psychological and somatic outcomes, and none were targeted for PRD, such as the system [ 56 ].

Moreover, related to symptom inputs, we found that current tools for pinpointing severe symptoms, such as the CDC’s UWS did not provide sufficient nuance for concerning psychological symptoms. Symptom-reporting tools for PRD will either need to consider incorporating structured assessments, such as the Edinburgh Postnatal Depression Scale (EPDS) [ 56 ], or incorporating additional symptoms. The latter approach may have advantages as the EPDS focuses on depression (while providing subscales for anxiety) and PROs evaluated for use with anxiety disorders have limitations [ 57 ]. Furthermore, the EPDS has been validated in in-person laboratory settings but not in community settings or for web-based entry [ 58 ]. We must also consider how mistrust in the health system may lead to less truthful answers. Issues expressed around stigma related to mental health indicate that the way in which these symptoms are elicited may require further assessment to promote the normalcy of the symptoms and improve candid reporting. Technology-based approaches for supporting perinatal mental health have been described as uniformly positive but having limited evidence for use [ 59 ], suggesting that further exploration is needed in this area, also considering how adding somatic issues may be perceived by patients.

Second, there were several drivers that affected symptom processing, decision-making, and action that cannot typically be solved through a symptom-reporting and decision-support system. Challenges related to self-perception and lack of experience or expectations may be addressed based on the wording for how the symptoms are elicited and by providing concise, easy-to-understand depictions of what should be expected versus what are the causes for concern. However, many of the other issues described related to sociocultural, financial, and environmental factors and the health systems’ systemic racism issues cannot be addressed directly in a simple PRO-based app and decision-support system. Directly addressing these issues will likely require more systematic, multipronged approaches. Therefore, it seems advisable to couple patient decision-support aids with other social support interventions for perinatal health [ 60 , 61 ].

Drivers of processing, decision-making, and action are still important contextual elements to be considered in the design of the system. Another study tailoring an mHealth app for Latina patients to support health during pregnancy also found it important to address issues related to financial barriers, social support, health care accessibility, and cultural differences [ 62 ]. Our best attempt to address these issues may be to promote information transparency and inclusive design. For example, there may be a “frequently asked questions” section of an app, where patients can explore things such as supportive resources for childcare while they seek medical attention or information they may show their friends or family members regarding postpartum symptoms of concern. The system may also use common human-computer interaction principles, such as information filtering [ 63 ] and organizing the suggested resources (eg, for mental health care) based on whether they accept the patient’s insurance. The built environment can also be changed through the system, but it may offer mechanisms for remote monitoring, such as telemedicine-based support or linking the system to a blood pressure cuff, when clinically appropriate [ 64 , 65 ]. As noted, the system obviously cannot address issues related to systematic racism directly [ 66 ]. Instead, we used a participatory design approach, with the hope that the nature of the information presented may be more patient centered, acceptable, and better aligned with the beliefs and values of Black patients [ 67 ]. Issues related to systematic racism have commonly been described in the US health care system, but structural inequities also exist on a global scale. Future studies should investigate how our findings regarding design needs may extend to other minoritized perinatal patient groups.

A systematic review of patient decision aids for socially disadvantaged populations across clinical settings found that such tools can improve knowledge, enhance patient-clinician communication, and reduce decisional conflict [ 68 ]. However, descriptions of patient decision aids focus on the type of tool (eg, paper vs digital), how it was delivered, when it was delivered, and by whom, as opposed to describing the content the aid provides. Therefore, it is challenging to determine how other decision-support tools have addressed information regarding environmental, financial, or health system–level factors that may affect care seeking based on the decision aid. Some tools seem to address sociocultural needs by tailoring to the target population, but the aforementioned systematic review did not find differential effects on outcomes when tools were tailored versus not tailored [ 16 ]. Future studies on patient decision aids may benefit from including non-symptom related information. Providing appropriate informational support may involve a deeper study of the systemic needs that patients may have, even if these needs may not directly be addressed by the decision aid.

Third, descriptions of the design needs for PRD symptom monitoring revealed that there is likely not a one-size-fits-all solution related to reminders, involvement of health professionals, and how the tool is incorporated with other systems (eg, the patient portal). “User control and freedom” and “flexibility of use” are two of the key items in commonly used heuristics for user interface design [ 69 ]; therefore, it is important to include options for customization and varied but safe pathways for interaction with the proposed system. For example, some participants described that they may not be likely to access the symptom-reporting system through the patient portal. Although there may be safety and convenience-related reasons for having the system as part of the patients’ medical record, if the patient chooses, the system could, on the front end, appear more like a stand-alone app than something that must be accessed through the patient portal. Patients also had varying opinions related to how they may want to reach out to a health professional if a problematic symptom was reported. These preferences may differ from instance to instance; therefore, it is helpful to ensure that patients have a choice regarding how to reach out, but system designers must also create workflows with feedback loop, so that patients who are reporting problematic symptoms are not missed (ie, if patients do not reach out themselves, they never receive attention). Patient-level customizations and options for interaction also respects patients as individuals and may promote patient-centered interactions.

Furthermore, related to design needs, participants indicated that the wording of the decision-support messages was critical. Specifically, for reports that did not include currently urgent symptoms, it was important that the message still conveyed support and validation, clarified that the patient could still reach out for help, and provided additional means for managing their symptoms, so the patient did not feel frustrated by their report [ 70 ]. Regarding messages that recommended patients to reach out to their health professional team, it was crucial to note what the symptom meant (eg, what kind of disease it could indicate), encourage the patient to reach out without increasing anxiety, and provide different avenues for easy outreach. Going forward, we plan to incorporate the aforementioned elements into the messages built into the system. We will then complete additional acceptance and comprehension testing with a larger sample of postpartum patients. These findings also indicate that care must be taken in translating such tools, and the translated materials should be reviewed with the target end user groups before implementation. This may mitigate unintended consequences or inadvertent inclusion of language that does not support the needs of minoritized groups.

Strengths and Limitations

Our study highlighted the limitations and areas that would benefit from further exploration. First, our study involved recruitment sites that were within a single health system in New York City. Second, while we achieved thematic saturation of qualitative themes (a means for determining sample sufficiency in qualitative studies) [ 54 , 55 ], our conclusions are based on a sample of 36 participants from 3 stakeholder groups. Third, given the documented disparities, we deliberately focused on the needs of Black postpartum patients, but this may not represent the needs of the postpartum patients of other races. Furthermore, our sample should not be viewed as encompassing the opinions of all Black postpartum patients. Our findings revealed the need for individual customization and varied interaction patterns on a case-by-case basis. Fourth, all interviews were conducted remotely (via Zoom or telephone), which can have effects on the interaction. On the one hand, it may be harder to connect with the interviewee, and on the other hand, people may feel more anonymous and comfortable with sharing information. Finally, although we attempted to promote external validity through the review of the coding scheme by a subject matter expert, we did not have the opportunity to perform triangulation of the findings by returning the results to participants. To address these limitations, it would be beneficial to survey a larger group of postpartum patients, powered to assess the differences based on race and ethnicity. This would allow us to come to a stronger consensus regarding design choices, assess whether there are differences in design needs or preferences, and gain feedback from patients in areas outside New York City. Future studies may also explore how other underserved groups, such as those with limited English proficiency, may benefit from tailored symptom self-monitoring and decision support.

Conclusions

In this qualitative study regarding postpartum symptom monitoring and decision support, we found that the current structured reporting measures do not include the combination of somatic and psychological symptoms that may be indicative of severe outcomes in the postpartum period. While not explicitly related to symptom reporting and decision support, patient decision aids, particularly those focusing on minoritized groups, should consider how the aids may be coupled with other structural support interventions or, at least, information about how other resources may be accessed. As stated in the commonly accepted design heuristics, we also found that user control and freedom unsurprisingly remain important for a patient decision-support aid for Black postpartum patients. Finally, decision aid–related phrases must take care to convey urgency without inducing anxiety when action may be indicated and consider respect and empathy for the patients’ symptoms when action may not be indicated to ensure that they do not feel unheard and are empowered to report new or worsening symptoms.

Acknowledgments

This study was supported by the National Institute on Minority Health and Health Disparities (K99MD015781; principal investigator: NB).

Data Availability

The data sets generated and analyzed during this study are not publicly available due to institutional review board regulations but are available from the corresponding author on reasonable request.

Authors' Contributions

NB conceptualized the study and acquired funding under the advisement of RBK, LER, AH, RMC, and JSA. NB collected the data. NB, SW, and SNdR analyzed the data with input from all other authors. ECP completed the literature review and descriptive analysis of participants’ characteristics. NB drafted the paper and received substantial inputs from all other authors.

Conflicts of Interest

LER is an Up to Date contributor and an advisory board member for the New English Journal of Medicine, and Contemporary OB/GYN. She has also been a speaker for Medscape is an an expert reviewer for Pfizer on the RSV Vaccine. AH is an Up to Date contributor, a co-founder and medical consultant for Iris Ob Health, and a consultant for Progyny.

Semistructured interview guide questions for patients and health professionals.

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Abbreviations

Edited by A Mavragani; submitted 22.03.23; peer-reviewed by C Laranjeira; comments to author 15.01.24; revised version received 20.02.24; accepted 08.03.24; published 26.04.24.

©Natalie Benda, Sydney Woode, Stephanie Niño de Rivera, Robin B Kalish, Laura E Riley, Alison Hermann, Ruth Masterson Creber, Eric Costa Pimentel, Jessica S Ancker. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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About 1 in 5 U.S. teens who’ve heard of ChatGPT have used it for schoolwork

Roughly one-in-five teenagers who have heard of ChatGPT say they have used it to help them do their schoolwork, according to a new Pew Research Center survey of U.S. teens ages 13 to 17. With a majority of teens having heard of ChatGPT, that amounts to 13% of all U.S. teens who have used the generative artificial intelligence (AI) chatbot in their schoolwork.

A bar chart showing that, among teens who know of ChatGPT, 19% say they’ve used it for schoolwork.

Teens in higher grade levels are particularly likely to have used the chatbot to help them with schoolwork. About one-quarter of 11th and 12th graders who have heard of ChatGPT say they have done this. This share drops to 17% among 9th and 10th graders and 12% among 7th and 8th graders.

There is no significant difference between teen boys and girls who have used ChatGPT in this way.

The introduction of ChatGPT last year has led to much discussion about its role in schools , especially whether schools should integrate the new technology into the classroom or ban it .

Pew Research Center conducted this analysis to understand American teens’ use and understanding of ChatGPT in the school setting.

The Center conducted an online survey of 1,453 U.S. teens from Sept. 26 to Oct. 23, 2023, via Ipsos. Ipsos recruited the teens via their parents, who were part of its KnowledgePanel . The KnowledgePanel is a probability-based web panel recruited primarily through national, random sampling of residential addresses. The survey was weighted to be representative of U.S. teens ages 13 to 17 who live with their parents by age, gender, race and ethnicity, household income, and other categories.

This research was reviewed and approved by an external institutional review board (IRB), Advarra, an independent committee of experts specializing in helping to protect the rights of research participants.

Here are the questions used for this analysis , along with responses, and its methodology .

Teens’ awareness of ChatGPT

Overall, two-thirds of U.S. teens say they have heard of ChatGPT, including 23% who have heard a lot about it. But awareness varies by race and ethnicity, as well as by household income:

A horizontal stacked bar chart showing that most teens have heard of ChatGPT, but awareness varies by race and ethnicity, household income.

72% of White teens say they’ve heard at least a little about ChatGPT, compared with 63% of Hispanic teens and 56% of Black teens.
75% of teens living in households that make $75,000 or more annually have heard of ChatGPT. Much smaller shares in households with incomes between $30,000 and $74,999 (58%) and less than $30,000 (41%) say the same.

Teens who are more aware of ChatGPT are more likely to use it for schoolwork. Roughly a third of teens who have heard a lot about ChatGPT (36%) have used it for schoolwork, far higher than the 10% among those who have heard a little about it.

When do teens think it’s OK for students to use ChatGPT?

For teens, whether it is – or is not – acceptable for students to use ChatGPT depends on what it is being used for.

There is a fair amount of support for using the chatbot to explore a topic. Roughly seven-in-ten teens who have heard of ChatGPT say it’s acceptable to use when they are researching something new, while 13% say it is not acceptable.

A diverging bar chart showing that many teens say it’s acceptable to use ChatGPT for research; few say it’s OK to use it for writing essays.

However, there is much less support for using ChatGPT to do the work itself. Just one-in-five teens who have heard of ChatGPT say it’s acceptable to use it to write essays, while 57% say it is not acceptable. And 39% say it’s acceptable to use ChatGPT to solve math problems, while a similar share of teens (36%) say it’s not acceptable.

Some teens are uncertain about whether it’s acceptable to use ChatGPT for these tasks. Between 18% and 24% say they aren’t sure whether these are acceptable use cases for ChatGPT.

Those who have heard a lot about ChatGPT are more likely than those who have only heard a little about it to say it’s acceptable to use the chatbot to research topics, solve math problems and write essays. For instance, 54% of teens who have heard a lot about ChatGPT say it’s acceptable to use it to solve math problems, compared with 32% among those who have heard a little about it.

Note: Here are the questions used for this analysis , along with responses, and its methodology .

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Olivia Sidoti is a research assistant focusing on internet and technology research at Pew Research Center

Jeffrey Gottfried is an associate director focusing on internet and technology research at Pew Research Center

Many Americans think generative AI programs should credit the sources they rely on

Americans’ use of chatgpt is ticking up, but few trust its election information, q&a: how we used large language models to identify guests on popular podcasts, striking findings from 2023, what the data says about americans’ views of artificial intelligence, most popular.

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subjective judgments (McConnell 2003, 217). Therefore, the person carrying out the training needs analysis must provide mechanisms to ensure confidentiality of the data collected and advise respondents that such is the case before beginning data collection (Rothwell and Kazanas 1998, 78). Training Need Analysis Process(McGhee and Thayer Approach):
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TNA is an important step (which occurs at the initial planning stage) in the training and development process (Carlisle et al., Citation 2011; Khan & Masrek, Citation 2017; Tao et al., Citation 2006).TNA is a strategic process that involves identifying the organizational goals, competency gathering and analyzing the information, determining the gaps between the current situation and the future ...
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The Hennessy-Hicks Training Needs Analysis (TNA) ... it was not surprising that training needs in research competences emerged as top priorities across studies conducted in MICs and LICs. ... Hilan A, Kawonal Y. The training and development needs of nurses in Indonesia: paper 3 of 3. Hum Res Health. 2006; 4:10. doi: 10.1186/1478-4491-4-10. [PMC ...
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Training needs assessment is an ongoing process of gathering data to determine what training needs exist so that training can be developed to help the organization accomplish its objectives. Conducting needs assessment is fundamental to the success of a training program. Often, organizations will develop and implement training without first ...
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Introduction. Training needs analysis (TNA) is a relatively new concept for nursing, but has been used for many years by human resource managers (Bee and Bee, 1994), in business (Pearson, 1987), industry (Boydell, 1976) and general education (Walklin, 1991).A considerable literature has developed around TNA and this has stimulated the publication of numerous standard textbooks (see for example ...
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Global demand for standardized assessment of training needs and evaluation of professional continuing education programs across the healthcare workforce has led to various instrumentation efforts. The Hennessy-Hicks Training Needs Analysis (TNA) questionnaire is one of the most widely used validated tools. Endorsed by the World Health Organization, the tool informs the creation of tailored ...
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A training needs analysis was defined for this study as the initial step in a process that contributes to an overall training and educational strategy for staff in an organisation or professional group (Gould et al., 2004) in this instance a group of nurses who worked within primary care in a small urban centre in New Zealand. 3. Research design
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Training Needs Assessment for Nurses in Sennar State, Sudan: Cross Sectional Study (1) The issue of TNA is addressed, which means that TNA must be an activity that precedes the preparation and implementation of training programs, and its accompanying paper will consider the issue of training evaluation in Sudan.
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A new Training Needs Analysis (TNA) approach was applied to an AV case study. • A Hierarchical Task Analysis was performed to establish the overall goal and tasks. • 7 main tasks were identified and decomposed into 26 sub-tasks and 2428 operations. • The KSA taxonomy was combined with driver training themes to produce training needs. •
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Training needs analysis (TNA), sometimes called training needs assessment, is the process of identifying what training is needed. The goal of TNA is to identify the precise knowledge, skills, or attitudes (KSAs) necessary for workers to perform their jobs efficiently and effectively and to compare how well individuals are presently equipped to do their jobs based on what they know and can do ...
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Research is making it increasingly clear that numerous issues in HR operations such as poor wages and the absence of performance assessment benchmarks are prevalent in developing nations, 8-10 as well as issues with poor Human Resource Development (HRD) analyses in the Gulf Cooperation Council (GCC) of Nations, especially Saudi Arabia. 9,11 Thus, the present study aims to evaluate the ...
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A Research Paper Submitted in Partial Fulfillment of the Requirements for the Master of Science Degree In ... University of Wisconsin-Stout Menomonie, WI 54751 Author: Nfila Cecilia Title: Training Needs Analysis for Bachibanga Company in Botswana Graduate Degree1 Major: MS Training and Development Research Advisor: David A. Johnson, Ph.D. ...
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This depends on 'training needs analysis' which is the first step in the entire process of training and development. Managers should avoid: Making snap assumptions about performance problems Organizing training without first establishing a need. Taking a one size fits all approach.
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Journal of Medical Internet Research
Background: Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias.
Use of ChatGPT for schoolwork among US teens
Pew Research Center conducted this analysis to understand American teens' use and understanding of ChatGPT in the school setting. The Center conducted an online survey of 1,453 U.S. teens from Sept. 26 to Oct. 23, 2023, via Ipsos. ... solve math problems and write essays. For instance, 54% of teens who have heard a lot about ChatGPT say it ...

Training needs assessment: tool utilization and global impact

Shreya Malhotra

Rebecca Billings

Conclusions

Search strategy – eligibility criteria

Data extraction and quality appraisal

Individual training needs analysis

Team/Interprofessional training needs analysis

Organizational training needs analysis

TNA tool utilization across the globe

Global impact in continuous professional development

Strengths and limitations

Implications

Acknowledgements

Abbreviations

Availability of data and materials

Contributor Information

Training needs assessment: tool utilization and global impact

Conclusions

Search strategy – eligibility criteria

Data extraction and quality appraisal

Individual training needs analysis

Team/Interprofessional training needs analysis

Organizational training needs analysis

TNA tool utilization across the globe

Global impact in continuous professional development

Strengths and limitations

Implications

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

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Consent for publication

Additional information

Rights and permissions

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BMC Medical Education

The Current State of Research on Training Effectiveness

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Training Needs Analysis (TNA) in the Organization

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