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

Abstract

Background

Clinical competency is essential for safe, high-quality nursing care, yet its acquisition and sustained maintenance remain challenging in Ghana due to fragmented Continuing Professional Development systems, theory–practice gaps, and resource constraints. Evidence on how nurses in Ghana develop and maintain competence has been scattered and insufficiently synthesized. Therefore, this study synthesized evidence on the barriers and facilitators to clinical competency acquisition and maintenance among nurses in Ghana.

Methods

We conducted a convergent integrated mixed-methods systematic review following the Joanna Briggs Institute methodology and PRISMA guidelines. Searches were conducted across MEDLINE, CINAHL, Scopus, and Embase, covering publications from 2000 to 2026. Twelve eligible empirical studies involving nurses, midwives, and nurse educators in Ghana were included. Data were synthesized narratively, guided by Benner’s Novice-to-Expert Model and Situated Learning Theory.

Results

Out of the 379 articles retrieved, 12 studies comprising 2,662 participants were included in this review. The most frequently reported barriers included inadequate structured clinical training, workforce shortages, resource constraints, limited managerial support, and inconsistent competency assessment. Key facilitators included structured mentorship and preceptorship programs, continuous professional development, supportive leadership, competency-based curricula, and positive workplace learning environments.

Conclusion

Nurses in Ghana face multilevel, system-driven challenges in acquiring and sustaining clinical competence. The Nursing and Midwifery Council of Ghana should strengthen competency-based regulation by institutionalizing structured mentorship and preceptorship programs, competency validation, and nationally coordinated continuing professional development. Implementing these reforms is essential to developing a competent, resilient, and practice-ready nursing workforce in Ghana and other resource-constrained settings.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05320-5.

Introduction

Nursing competency is fundamental to safe, effective, and high-quality healthcare delivery, underpins the quality and integrity of patient care worldwide. With approximately 29.8 million nurses worldwide, nurses constitute the largest segment of the global health workforce, underscoring their pivotal role in advancing health priorities and sustaining patient safety across all levels of care [1–3]. Clinical competency is widely recognized as a multidimensional construct that integrates technical proficiency, critical thinking, ethical decision-making, and effective communication [1, 4]. It reflects a nurse’s ability to apply knowledge and skills to deliver evidence-based, patient-centered care within complex and evolving health systems [5]. To remain clinically competent, nurses require ongoing opportunities to update their skills, knowledge, and judgment throughout their careers [6, 7]. Hence, competency acquisition and maintenance have become central priorities in nursing education, practice, and policy globally.

Given that nursing competency must be continuously developed, global health systems have increasingly adopted structured mechanisms to sustain and evaluate professional competence. Continuous Professional Development (CPD) and competency-based education models have emerged as central strategies for ensuring nursing competence. The World Health Organization (WHO) underscores that a competent nursing workforce is indispensable for achieving universal health coverage and Sustainable Development Goal 3, and has developed a global competency framework to guide professional development [8]. In many high-income countries, these frameworks are supported by robust systems of clinical mentorship, simulation-based learning, and regulatory audits that reinforce continual skill enhancement and accountability [9–11]. However, implementing and sustaining these approaches remains challenging in many low- and middle-income countries (LMICs) [12, 13].

In Ghana, the institutionalization of competency-based frameworks and CPD remains inconsistent. Despite efforts by the Nursing and Midwifery Council of Ghana (NMC-GH) to mandate annual CPD for license renewal, significant disparities persist in access, implementation, and relevance [14]. Although CPD opportunities have expanded through online platforms, concerns remain regarding their practical application, particularly the limited simulation and hands-on learning [12]. This imbalance compromises skill retention, procedural confidence, and practical application, particularly among rural nurses who face additional barriers such as time constraints, limited funding, and inadequate institutional support [15]. Consequently, although CPD initiatives have expanded, they have not sufficiently bridged the gap between theoretical knowledge and clinical proficiency in the Ghanaian context.

The problem is compounded by a persistent theory-practice gap, a well-documented challenge in nursing education across sub-Saharan Africa. Studies reveal that newly qualified nurses often struggle to translate classroom knowledge into clinical decision-making due to inadequate preceptorship, insufficient supervision, and limited access to simulation-based training [16, 17]. The absence of structured clinical mentorship undermines confidence and performance, leaving novice nurses reliant on outdated or inconsistent practices [18]. In Ghana, systemic inadequacies, ranging from overcrowded curricula to limited faculty expertise and poor clinical placement coordination, further perpetuate this gap [14].

Effective regulation and institutional enforcement are critical to addressing these competency gaps. However, although Ghana’s regulatory framework has made notable progress compared to some sub-Saharan countries, institutional enforcement remains weak, with limited guidelines for in-house training and insufficient monitoring of post-qualification skill retention [19]. Additionally, Ghana lacks standardized systems for clinical sign-offs or competency validation before nurses undertake independent practice. This regulatory gap leaves many practitioners without structured mechanisms to assess or renew their clinical proficiency, creating variability in care quality across institutions [19].

Although studies have examined clinical competency among nurses in Ghana, the evidence remains fragmented across educational, clinical, institutional, and regulatory domains. Existing studies have largely focused on specific aspects of competency development, with limited synthesis of the barriers and facilitators influencing competency acquisition and maintenance across settings [14, 19]. Moreover, qualitative and quantitative evidence has not been comprehensively integrated to provide a broader understanding of these factors. Thus, to date, no mixed-methods systematic review has comprehensively synthesized qualitative and quantitative evidence on the barriers and facilitators influencing competency acquisition and maintenance among nurses in Ghana. This review addresses this gap by integrating evidence from diverse methodological approaches to inform nursing education, clinical practice, and policy.

Therefore, this systematic review seeks to synthesize evidence on the barriers and facilitators to the acquisition and maintenance of clinical competency among nurses in Ghana. The review is guided by an integrated conceptual framework combining Benner’s Novice-to-Expert Model [20] and Lave and Wenger’s Situated Learning Theory [21]. Benner’s model explains how nurses develop competence through experience, reflective practice, and progressive skill acquisition, whereas Situated Learning Theory emphasizes that competence is shaped through participation in authentic clinical environments, mentorship, and communities of practice. Together, these complementary perspectives provide the analytical lens for understanding how individual learning and workplace contexts influence competency development. The findings will inform policy reforms, guide educational and institutional initiatives, and contribute to strengthening nursing practice and healthcare quality in Ghana and other low- and middle-income countries.

Methods

Study design

This review employed a convergent integrated mixed-methods systematic review design in accordance to the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [22]. The convergent integrated mixed-methods systematic review was considered the most appropriate design because it enabled qualitative and quantitative evidence to be integrated into a comprehensive understanding of the factors influencing clinical competency acquisition and maintenance among nurses. The review was reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [23]. It was also reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guideline [24]. Based on this structure, the review sought to answer the question: “What evidence exists on how nurses in Ghana acquire and maintain clinical competency, and what factors influence this process?” We registered the protocol for this review on the Open Science Framework database (osf.io/kjdea).

Inclusion and exclusion criteria

Studies were included if they were peer-reviewed empirical publications written in English and conducted in Ghana between January 2000 and January 2026. Ghana was selected as the sole context because differences in nursing education systems, professional regulation, clinical practice environments, and competency assessment frameworks across countries could introduce substantial contextual variation, making a Ghana-specific review more appropriate for ensuring consistency in evidence synthesis. This timeframe was selected to capture the contemporary evolution of nursing education, clinical practice, and competency development in Ghana. Eligible studies were required to involve nurses, midwives, nurse educators, or nursing administrators and to examine clinical competency acquisition, maintenance, or assessment. Studies were also eligible if they explored strategies such as continuing professional development, in-service training, mentorship, preceptorship, simulation-based learning, clinical supervision, or regulatory and institutional mechanisms that influence competency. Studies focusing on the healthcare system’s influence on competency were also included. Studies were excluded if they focused solely on non-nursing professionals, addressed competence exclusively in a theoretical educational context without application to clinical practice, were not empirical in nature, or lacked full text. Editorials, commentaries, opinion papers, and conference abstracts were also excluded.

Search strategy

An initial exploratory search was conducted in Google Scholar and PubMed to assess the volume and nature of available literature and to refine search terms and indexing vocabulary. Following this, a comprehensive search strategy was developed in consultation with a health sciences librarian (YF) from the University of Maryland, Baltimore, and applied across multiple databases, including MEDLINE, CINAHL, Scopus, and Embase. Searches covered publications from January 2000 to January 2026. The strategy combined controlled vocabulary such as Medical Subject Headings (MeSH) with relevant keywords related to clinical competence, nursing skills, continuing professional development, mentorship, supervision, workplace learning, and Ghana. A detailed overview of the full search strategy and the number of results retrieved from each database is presented as attached file (Supplementary Material, Table S1). All retrieved records were exported into Covidence [25], where automated deduplication was undertaken prior to screening.

Study selection

Study selection was conducted in Covidence. Two reviewers (DBA and EWV) independently screened all titles and abstracts according to the predefined eligibility criteria. Inter-rater agreement for title and abstract screening was assessed using Cohen’s kappa coefficient (κ = 0.558) [26]. Articles deemed potentially relevant were retrieved for full-text screening, which was also conducted independently by the same reviewers. Inter-rater agreement for full-text screening was similarly assessed using Cohen’s kappa coefficient (κ = 0.364). The modest agreement at both stages may reflect differences in reviewers’ interpretation of eligibility criteria and variability in how study characteristics and competency-related outcomes were reported across studies. Any disagreements arising during either screening stage were resolved through discussion, and unresolved discrepancies were adjudicated by a third reviewer (AA). To ensure comprehensive coverage, reference lists of all included studies were manually reviewed to identify any additional eligible articles. Reasons for exclusion at the full-text screening stage were documented. The selection process was reported using a PRISMA flow diagram (Fig. 1).

Fig. 1 .

PRISMA flowchart for study selection

Data extraction

Data were extracted using the Joanna Briggs Institute (JBI) standardized data extraction tool, which was adapted to the objectives of the review and piloted prior to full use [22]. Extracted information included author details, publication year, study objectives, study setting, design and methodology, participant characteristics, and key findings relevant to competency acquisition and maintenance (Table 1). Two reviewers (DBA and EWV) independently extracted data from all included studies and cross-checked the completed extraction forms for consistency and completeness. Any discrepancies or inconsistencies were discussed and resolved through consensus. Both qualitative and quantitative data were extracted from the included studies.

Table 1.

Summary of the included studies

No.	Author (Year)	Study aim	Study area	Study design	Participants characteristics	Findings
1	Kobekyaa & Naidoo (2023) [31]	To describe the experiences of collaborative clinical facilitation among nurse educators, clinical preceptors, and final-year nursing and midwifery students in Northern Ghana	Two nursing and midwifery training colleges and an academic hospital in Northern Ghana	Qualitative, descriptive	46 participants; 20 final-year students, 16 nurse educators, 10 clinical preceptors from the teaching hospital; mid-20s to mid-40s	Barriers • Inadequate one-to-one supervision due to limited staff, leaving students feeling unsupported, especially during critical clinical exam preparation periods. • Overburdened preceptors sometimes expressed frustration and anger toward students, creating emotionally stressful learning environments that undermined confidence and learning. • Some nurse educators lacked up-to-date clinical experience or had non-nursing backgrounds, limiting their ability to effectively mentor students in clinical practice. • Staff shortages and workload pressure resulted in too few preceptors relative to student numbers, limiting supervision. • Overwhelmed dual responsibilities (patient care and teaching), reducing available time for student guidance. • Nurse educators faced heavy academic workloads and large class sizes, constraining their clinical supervision capacity. • Time constraints meant some students received minimal support, and important activities such as clinical conferences were sometimes missed. • Students expressed concern about graduating with insufficient clinical competence due to limited structured clinical teaching. • Weak coordination and communication between training institutions and hospitals, including poor notification of placements and unclear learning objectives. • Disorganized placement arrangements sometimes led to students being turned away or missing learning opportunities. • System-wide shortages of nurse educators and clinical preceptors limited capacity for quality clinical training. • Structural human resource deficits risked producing graduates with competency gaps due to reduced clinical exposure and guidance. Facilitators • Personalized preceptorship provided close mentoring, direct feedback, and safe guided practice, supporting skill acquisition and exam preparedness. • Supportive team supervision by tutors, clinical preceptors, and ward staff strengthened students’ confidence, self-efficacy, and professional identity. • Positive mentorship relationships fostered professional socialization and enhanced clinical competence. • Team-based collaborative mentorship in clinical settings allowed students to benefit from multiple experienced practitioners. • Joint supervision supported safe clinical learning, ensuring students practiced skills under guided oversight while minimizing patient harm. • Collaborative clinical environments promoted open communication, peer learning, and confidence building. • Participation in clinical teaching helped educators maintain and update their own clinical skills, reinforcing quality teaching. • Clinical conferences provided structured opportunities for reflection, case discussion, shared learning, and feedback, enhancing comprehension and competence. • National regulatory requirements encouraged nurse educators to engage in clinical supervision as part of professional license renewal, strengthening practice–education linkage. • Institutionalizing mentorship programs and clinical conferences demonstrated systemic commitment to collaborative clinical education. • Structured stakeholder engagement (educators, clinicians, students) supported alignment of training goals and reinforcement of clinical competency development.
2	Konlan et al. (2024) [35]	To describe nurses’ clinical competency and research knowledge/skills in Ghana regarding evidence-based practice (EBP).	Nationwide study	Descriptive cross-sectional survey	480 clinical nurses and nurse educators; 60.2% were female; mean age 36.6 years; 56% married; 85% were Christian; 95% were full-time employees	Barriers • Approximately 30% resisted changing established clinical practices, preferring “trusted” traditional methods. • About 20% expressed neutral or negative attitudes toward incorporating research into their own practice. • Nurses not encouraging students to integrate theory and evidence into practice, weakening competency transfer. • Heavy workloads restricted nurses’ ability to update knowledge, engage with new evidence, or attend training. • Workplace cultures sometimes favored routine practice over innovation, discouraging adoption of new evidence. • Some nurses reported that EBP was not routinely integrated into daily care or mentorship activities. • Lack of structured support for on-the-job learning hindered competency development and maintenance. • Nurses with only undergraduate education had significantly lower EBP knowledge, skills, and self-rated competence compared to those with postgraduate training. • Nursing education programs may not adequately prepare nurses in research and EBP competencies. • Ghana lacks a formal national system for routine competency assessment or structured continuing professional development (CPD) tracking. • Absence of sustained policy-driven mechanisms contributes to competency decline over time. Facilitators • Many nurses indicated openness to adopting EBP in practice if provided support. • The need for hospital leadership engagement to create enabling learning environments. • Workplace-based EBP training programs were identified as key facilitators for competency growth. • Recommended interventions include in-service workshops, mentorship, opportunities for skill reinforcement, and protected learning time. • Strengthening national education policies to integrate EBP rigorously into nursing curricula could enhance competency acquisition. • Authors recommend mandatory and structured CPD programs to support ongoing competence maintenance. • National regulatory bodies (e.g., Nursing and Midwifery Council) can drive improvement through policy frameworks for continuous evaluation and training. • Investments in advanced nursing education, curriculum reform, and standardized competency assessment systems were essential enablers.
3	Ibrahim et al. (2025) [41]	To assess the impact of nurses’ patient safety competency (PSC) on key patient safety outcome indicators (KPIs) for patient safety outcomes at Tamale Teaching Hospital	Tamale Teaching Hospital (TTH) in Northern region	Multi-method design	291 nurses participated in the survey; 59.5% were 20–29 years old) and 55.3% were female; Diploma in Nursing (71.5%) and having less than 5 years of clinical experience.	Barriers • Lower patient safety competency among nurses with limited education, fewer years of experience, and junior professional rank. • Inadequate formal patient safety education during pre-service training • Knowledge gaps at entry into practice due to inconsistent and fragmented exposure to safety principles. • Lack of regular in-service training focused on patient safety; existing trainings prioritize clinical conditions and administration. • Exclusion of frontline nurses from available workshops, limiting equitable access to competency development. • Absence of standardized patient safety protocols, leading to reliance on personal judgment and inconsistent practices. • Restrictive career advancement and study-leave policies, limiting opportunities for further education and skill upgrading. • Narrow scope of practice and rigid task allocation, restricting opportunities to apply judgment and broaden clinical skills. • Unsupportive or punitive leadership, discouraging error reporting and undermining confidence in applying safety competencies. • Poor integration of patient safety into national nursing curricula, resulting in weak foundational competency. • Restrictive health and education policies limiting nursing autonomy and professional development. • Lack of national patient safety standards and guidelines, leading to variability across facilities. • Resource constraints (staffing, equipment, funding) and limited prioritization of patient safety at policy level. Facilitators • Higher educational attainment, longer clinical experience, senior rank, and prior safety training associated with stronger competency. • Targeted capacity-building interventions (e.g., EBP training, simulation, participation in quality improvement activities) identified as key enablers • Inclusive, regular workplace training and refresher programs on patient safety. • Availability of clear, evidence-based safety guidelines and routine performance monitoring. • Supportive leadership and positive safety culture, characterized by open communication, non-punitive responses to errors, and accountability. • Expanded roles and rotational task assignments enabling broader clinical exposure and skill application. • Curriculum reform introducing dedicated patient safety courses and structured competency modules. • Policy reforms supporting nursing autonomy, continuing professional development, and career progression. • Development of national standardized patient safety protocols to guide practice uniformly. • Increased resource allocation and policy prioritization for patient safety training and monitoring.
4	Tornu et al. (2020) [36]	To investigate final-year student nurses’ self-assessed TB/HIV coinfection care skill-competence and its determinants.	Four nursing training institutions (two public nursing colleges and two nursing universities) in the Greater Accra Region	Descriptive cross-sectional survey	348 final-year student nurses (236 in a 3-year Diploma program; 112 in a BSc Nursing program); 19–37 years old; predominantly female (79.8%).	Barriers • Direct-entry BSc nursing students without prior nursing qualifications demonstrated significantly lower competence than diploma-trained or post-diploma BSc students. • Students without prior clinical experience showed lower self-assessed competence. • Training in public nursing institutions was associated with lower TB/HIV care competence compared to private institutions. • Limited early clinical immersion in BSc programs constrained skill development. • Insufficient hands-on TB/HIV training during pre-service education, with over 70% of students unable to perform key tasks proficiently. • Mismatch between task-shifting policies and training outcomes, with many graduates not fully competent to independently manage TB/HIV care. • Poor integration of WHO TB/HIV guidelines into nursing education, reflected by low guideline awareness among students. Facilitators • Older age and greater clinical exposure were associated with higher care competence. • Prior TB/HIV care experience significantly improved competence levels. • Having a previous nursing qualification (diploma or post-diploma BSc) facilitated higher competence. • Awareness of WHO TB/HIV task-shifting guidelines was associated with better competence. • Training in private nursing institutions supported higher competence. • Diploma programs’ strong clinical focus and early practicum exposure enhanced skill acquisition. • Educational environments emphasizing extensive supervised clinical practice improved TB/HIV care competence. • Dissemination and integration of standardized WHO TB/HIV guidelines into training improved competence. • Strong policy guidance coupled with investment in clinical training enabled better acquisition and maintenance of TB/HIV care competence.
5	Salifu et al. (2022) [32]	To explore nurse educators’ perceptions and challenges in teaching practical skills and facilitating the development of clinical competence in diploma nursing education in Ghana.	Ghana (three nursing colleges and affiliated clinical practice sites across northern, middle, and southern zones).	Qualitative descriptive study	9 nurse educators (7 females, 2 males); 26–55 years	Barriers • Limited pedagogical preparation among nurse educators, resulting in overreliance on lecture and demonstration methods that inadequately support critical thinking and clinical reasoning. • High educator workload and role overload, driven by poor educator–student ratios and competing academic responsibilities, reducing capacity for effective skills facilitation. • Reduced educator motivation linked to stress, fatigue, and limited incentives for professional development. • Poor student engagement in practical skills learning, characterized by minimal deliberate practice and exam-oriented attitudes. • Inadequate and overcrowded skills laboratories, with shortages of equipment, consumables, and updated teaching materials. • Insufficient time allocated for practical teaching and independent skills practice due to large class sizes and curriculum pressure. • Weak clinical placement support, with inconsistent supervision and students frequently used as substitute workforce. • Poor collaboration between nursing colleges and clinical facilities, contributing to persistent theory–practice gaps. • Delayed procurement and limited managerial support restricting access to essential teaching resources. • Limited regulatory support for nurse educator preparation, refresher training, and career development. • Absence of structured preceptorship systems to support consistent clinical competence development. • Outdated nursing curricula with insufficient emphasis on practical competence and excessive theoretical focus. • Rapid student enrolment expansion without proportional investment in infrastructure, educators, or learning resources. • Weak quality assurance mechanisms for monitoring clinical competence acquisition and teaching effectiveness. Facilitators • Strong intrinsic motivation and commitment to practical skills teaching among some nurse educators. • Recognition of simulation-based pedagogy as an effective approach for clinical competence development when adequately resourced • Informal educator–clinician collaboration to support student learning in clinical settings. • Adaptive teaching strategies (e.g., improvisation, videography) to mitigate resource limitations. • Broad recognition of the need for curriculum reform, standardization of practical skills teaching, and strengthened regulatory oversight. • Calls for increased national investment in nursing education infrastructure and nurse educator development.
6	Yarney et al. (2021) [39]	To explore the ability, role, and experiences of university nurse academics in Ghana in balancing theoretical training with clinical practice in nursing education	Two public institutions and one private university; University of Ghana (Accra), the University of Health and Allied Sciences (Ho), and Valley View University (Accra)	Mixed methods; Qualitative-driven exploratory study with methodological triangulation	Survey: 80 participants;30 nursing lecturers; 50 final-year (Level 400) nursing students Qualitative Component: 25 participants; 5 lecturers and 20 students 5 lecturers and 20 students; Mostly early-career academics (2-3years of clinical experience; 30–40 years	Barriers • Limited clinical experience among nursing lecturers reduced confidence and effectiveness in skills teaching. • Some educators showed low commitment to maintaining clinical practice after transitioning to academia. • Mismatch between lecturers’ self-perceived competence and students’ perceptions undermined trust and learning. • Students reported difficulty learning practical skills from lecturers perceived as clinically inexperienced. • Inadequate and inconsistent clinical mentorship during hospital placements. • Preceptors often unavailable due to workload or scheduling conflicts. • Hostile or competitive clinical environments discouraged staff from teaching students. • Limited supervision forced students to learn independently, slowing skill development. • Rigid university academic calendars limited time allocated for clinical practice. • Nursing programs lacked autonomy to schedule sufficient practical sessions. • Bachelor’s-prepared nurses entered senior roles immediately after graduation, bypassing junior apprenticeship. • Limited enforcement of regulatory requirements for educators’ ongoing clinical practice. • Absence of monitoring mechanisms to ensure educators maintain clinical competence. Facilitators • Shared belief among lecturers and students that theory must be integrated with practice. • Students preferred and learned better from lecturers who could draw on real clinical experience. • Educators who actively linked theory to practice enhanced students’ competence acquisition. • Supportive clinical environments with welcoming staff improved learning. • Structured mentorship, teamwork, and low hostility enhanced competence development. • Positive staff attitudes toward teaching facilitated hands-on learning. • Greater curricular autonomy for nursing programs to expand clinical training. • Strengthened regulatory enforcement of clinical practice requirements for educators. • Policies mandating periodic clinical engagement to support competence maintenance.
7	Asiamah et al. (2016) [37]	To determine whether formal education, in-service training (IST), or job tenure best predicts healthcare performance in Ghana.	Accra North District, Ghana.	Cross-sectional quantitative survey	811 nurses; 65% female, 35% male; 49.7% bachelor’s, 31.6% diploma, 18.7% master’s	Barriers • Formal education level not significantly associated with clinical performance. • Job tenure alone did not improve competence without ongoing learning. • Infrequent or absent in-service training limited skill development and maintenance. • High staff turnover reduced returns on training investments and mentorship capacity. • Financial constraints limited ability to invest simultaneously in education and training. • Broader economic challenges restricted workforce development and training scale-up. Facilitators • Active participation in in-service training significantly improved performance. • Experience combined with continuous training enhanced competence. • Regular, structured in-service training strengthened clinical competence. • Organizational support for professional development (e.g., study leave, scholarships). • Non-financial retention incentives (recognition, career progression, work conditions). • Policy prioritization of in-service training identified as the most cost-effective strategy. • Integrated training and retention policies to sustain competence over time.
8	Adam et al. (2021) [38]	To assess the role of the clinical learning environment in shaping undergraduate nursing and midwifery students’ satisfaction with clinical rotation experiences.	Tamale, Ghana (University for Development Studies and affiliated clinical sites, primarily Tamale Teaching Hospital).	Quantitative cross-sectional survey	224 students; Undergraduate nursing and midwifery students; 23.8 years; General nursing (71.4%), midwifery (28.6%)	Barriers • Lower satisfaction and perceived competence when students experienced limited engagement, feedback, or support during rotations. • Reduced confidence and skill development when students felt excluded from clinical activities. • Unsupportive pedagogical atmosphere hindered learning and limited opportunities for hands-on skill practice. • Authoritarian or unsupportive ward leadership negatively affected students’ engagement and learning experiences. • Poor ward culture and weak information flow reduced meaningful clinical learning opportunities. • Weak coordination between nursing education institutions and clinical facilities (acknowledged contextually) may limit consistency in clinical learning. • Inadequate supervision structures can undermine competence acquisition if not addressed systemically. Facilitators • High overall satisfaction with clinical rotations (65.6%) supported perceived competence acquisition. • Students reported improved confidence and skill development when actively involved in patient care and supervised practice. • Supportive pedagogical atmosphere strongly enhanced clinical learning and competence development. • Democratic and student-supportive ward leadership facilitated skill acquisition. • Premises of nursing (positive ward culture, good documentation practices, inclusion of students, and availability of learning situations) had the strongest positive influence on clinical learning. • Regular supervision, feedback, and recognition of students as part of the care team improved competence development. • Strong institutional collaboration between the university and teaching hospital supported a structured and effective clinical learning environment. • Well-organized clinical placement systems and availability of preceptors enhanced clinical competence development.
9	Anim-Boamah et al. (2021) [19]	To explore nursing students’ experiences of clinical competency assessment as part of the national nursing licensing examination in Ghana.	Ghana (national scope); Eight Nursing Education Institutions across northern, middle, and southern zones.	Qualitative descriptive study	68 final-year students;; Diploma and Bachelor nursing programs; Public and private nursing colleges and universities	Barriers • Anxiety and confusion during assessment due to examiner hostility and shouting. • Reduced performance when students were intimidated, rushed, or denied clarification. • Falsification of patient problems in care plans due to time pressure, undermining true competence demonstration. • Incongruence between what is taught, practiced, and assessed, leading to poor skill transfer. • Use of outdated clinical procedure manuals, creating gaps between current practice and assessment expectations. • Limited access to assessment rubrics by educators and students, impairing preparation and formative learning. • Shortage of clinical staff and heavy workloads reduced supervision and hands-on teaching. • Poor feedback practices; lack of positive reinforcement even when tasks were performed correctly. • Unstandardised national clinical competency assessment system, compromising fairness, validity, and reliability. • Limited availability of clinical equipment and consumables across facilities, restricting skill practice. Facilitators • Pre-examination meetings with examiners reduced anxiety and improved psychological readiness. • Familiarity with clinical settings (assessment conducted in usual placement sites) supported confidence. • Clinical instructors’ efforts to compensate for outdated materials by sourcing alternative learning resources.
10	Anim-Boamah et al. (2022) [33]	To explore the perspectives of key informants on the clinical nursing competency assessment system used in Ghana’s nursing licensing examination.	Ghana (multiple Nursing Education Institutions and affiliated clinical practice facilities across regions)	Qualitative descriptive study	20 Key Informants; 10 Nurse educators; 8 Nurse clinician; 2 Nurse managers	Barriers • Students demonstrated limited competence in clinical reasoning and care planning, partly due to inadequate real-time observation during patient assessment. • Fabrication or memorization of care plans occurred when students were not observed interacting with patients. • Inconsistent understanding of nursing diagnoses due to variable teaching approaches across institutions. • Unstandardized teaching practices across clinical sites led to misalignment between what was taught and what was assessed. • Heavy ward workload limited opportunities for students to practice core competencies (e.g., nursing care plans). • Absence of nationally standardized competency assessment methods (e.g., OSCE). Facilitators • Exposure to structured, clearly defined competency expectations improved students’ preparedness for assessment. • Observation-based assessment (when rigorously applied) supported more accurate judgment of student competence. • Existence of a national licensing examination framework provided a foundation for standardization. • Proposed introduction of OSCE-based assessment viewed as a major system-level enabler for validity and reliability. • Integration of competency assessment results into curriculum review and policy reform.
11	Salifu et al. (2022) [34]	To explore the experiences and perceptions of diploma nursing students and post-registration nurses regarding the teaching and learning of clinical competence in Ghana	Ghana (three nursing colleges and affiliated clinical practice sites across northern, middle, and southern zones).	Qualitative descriptive study	55 participants; 40 diploma nursing students (second- and third-year); 15 post-registration nurses; drawn from six training and clinical sites	Barriers • Limited confidence and perceived personal inadequacy, particularly when required to independently perform clinical procedures in real patient settings. • Fear of making errors and harming patients, often intensified by threats of disciplinary action from clinicians. • Difficulty translating theoretical knowledge into practice, leading to hesitation and avoidance of advanced procedures. • Knowledge gaps related to unfamiliar equipment, which undermined performance during practical assessments. • Negative learner attitudes among some students, including truancy, lack of seriousness, and unwillingness to engage in clinical learning opportunities. • Overemphasis on theoretical instruction at nursing education institutions, with insufficient prioritization of practical skills development. • Inadequate skills laboratory infrastructure, including overcrowding, limited access, short practice time, and lack of essential equipment. • Restrictions on skills laboratory use, such as locked labs and fear of penalties for damaging equipment. • Unsatisfactory clinical teaching methods, including tutor reliance on lectures and slide presentations rather than hands-on demonstrations. • Negative nurse educator attitudes, including anger, poor communication, lateness, and authoritarian behaviors that discouraged learning. • Poorly planned clinical placements, characterized by: o Short placement duration o Random ward allocation o Lack of alignment between coursework and clinical exposure • Lack of supervision and mentorship in clinical practice sites, leaving students and post-registration nurses to function as full staff. • Use of students as extra labor, including excessive workload and non-educational errands during clinical hours. • Ward restrictions, where students were limited to basic tasks and prevented from performing key nursing procedures. • Hostile clinical environments, marked by bullying, shouting, humiliation, and fear-inducing behaviors from staff. • Patient resistance, with patients refusing care from students due to stigma or lack of trust. • Curriculum misalignment, with national nursing curricula heavily skewed toward theory at the expense of practice-based learning. • Absence of standardized national procedure manuals, leading to inconsistent teaching and confusion over correct clinical practices. • Weak collaboration between nursing education institutions and clinical practice sites, resulting in poor monitoring and accountability. • Delayed posting of post-registration nurses for mandatory internships, contributing to skill attrition after graduation. • Resource constraints across the health system, including shortages of equipment, supplies, and staffing. • Regulatory gaps, where oversight bodies failed to enforce uniform clinical teaching and assessment standards. Facilitators • Peer learning and peer tutoring, which helped students clarify procedures and reinforce skills outside formal instruction. • Deliberate self-practice, including repetition of procedures when opportunities were available. • Use of videos and self-directed learning, although participants noted contextual mismatches with local practice settings. • Skills laboratories, when accessible, were perceived as safer environments for learning correct procedures compared to wards. • Supportive clinicians, though limited in number, who actively taught and guided students during clinical placements. • Informal mentoring relationships, where students proactively sought supportive staff to enhance learning. • Hands-on exposure during clinical placement, despite limitations, provided opportunities to observe real-world practice. • Calls for curriculum reform, emphasizing practice-oriented and contextually relevant training. • Proposed integration of simulation-based clinical nursing education, adapted to low-resource settings. • Advocacy for structured support systems, such as preceptorship and clinical placement coordinators. • Policy recommendations to strengthen monitoring, supervision, and collaboration across education and practice sectors.
12	Sacks et al. (2015) [40]	To assess motivation and satisfaction of community health nurses (CHNs) in rural Ghana and how these relate to their clinical knowledge.	Five rural districts in Ghana (Ningo Prampram, Ada East and Ada West in Greater Accra; South Dayi and South Tongu in Volta Region)	Mixed methods	205 surveys; 29 interviewed CHNs and 23 CHNs in FGDs	Barriers • Insufficient resources: >80% of CHNs rated lack of transport, supplies and equipment as a primary obstacle to job performance; interviews highlighted broken refrigerators, faulty infant scales and staff shortages that hinder service delivery. • Limited career advancement: Over 80% reported few promotion opportunities as a major barrier. CHNs expressed frustration that advancing (e.g. to midwife or public health nurse) often requires leaving the CHN cadre entirely. • Low compensation: Nearly 60% of CHNs were dissatisfied with their pay and felt underpaid for their work, especially younger nurses. • Logistical workload: CHNs (particularly those at community posts) felt their work was especially demanding; extensive outreach on foot made CHN roles more physically/logistically difficult than facility-based roles. • Weak supervision: Many CHNs reported inconsistent or inadequate supervisory support. They noted that patients often showed them more appreciation than their supervisors did, and they desired more guidance and respect from managers. • Motivation–competence gap: CHNs with higher job satisfaction did not have significantly better clinical knowledge. Satisfied CHNs scored only marginally (non-significantly) higher on the MCH knowledge test. The authors conclude that improving motivation or satisfaction alone may not be sufficient to enhance clinical competence or job performance. Facilitators • Training and development: A large majority (71%) said that more in-service training was essential for their job satisfaction, and nearly half (48%) cited access to continuing education as critical for achieving future career goals. Access to more training resources was viewed as a key facilitator of competence and motivation.

Quality appraisal methods

The methodological quality of all included studies was appraised using the 2018 version of the Mixed Methods Appraisal Tool (MMAT) [27]. Each study was first categorized by study design (qualitative, quantitative descriptive, or mixed methods) to ensure application of the appropriate MMAT criteria (Supplementary file Material, Table S2). Two reviewers (DBA and EWV) independently conducted the appraisal. For quantitative studies, the assessment focused on sampling strategy, sample representativeness, measurement appropriateness, risk of non-response bias, and suitability of statistical analyses. Qualitative studies were evaluated based on the appropriateness of the qualitative approach, adequacy of data collection methods, coherence between data and findings, and the strength of interpretation. Mixed-methods studies were assessed for the rationale for using a mixed-methods design, the integration of qualitative and quantitative components, and the methodological quality of each component. Any discrepancies between reviewers were resolved by discussion to reach a consensus. In accordance with MMAT guidance, each criterion was rated dichotomously (Yes/No), generating a detailed profile of each study’s methodological strengths and limitations. To support contextual interpretation, we also extracted and reported sample sizes, sampling approaches, and key participant characteristics. No studies were excluded or weighted based on methodological quality; rather, the quality appraisal was used to contextualize the interpretation of the synthesized findings. Findings supported predominantly by studies with stronger methodological quality were interpreted with greater confidence, whereas findings derived mainly from studies with methodological limitations were interpreted cautiously.

Data synthesis

Quantitative findings were transformed into textual data through qualitization to facilitate their integration with qualitative evidence in this mixed-methods systematic review. Qualitization involved extracting the principal findings from quantitative studies and converting them into narrative statements that preserved their original meaning while enabling direct comparison with qualitative findings [28, 29]. In accordance with the JBI convergent integrated approach [30], the qualitized quantitative findings were combined with the qualitative findings into a single dataset for integrated analysis rather than being analyzed separately. The integrated dataset was subjected to iterative comparison to identify similarities, differences, and relationships across the evidence. Findings expressing similar concepts were coded and grouped according to shared meaning, irrespective of their methodological origin. These findings were then synthesized into thematic categories representing competency-building strategies, barriers, facilitators, and broader systemic influences (Supplementary Material, Table S3). Throughout this process, convergence and complementarity between qualitative findings and qualitized quantitative evidence were examined to develop a comprehensive understanding of competency acquisition and maintenance among nurses in Ghana.

The integrated thematic categories were subsequently interpreted using Benner’s Novice-to-Expert Model [20] and Lave and Wenger’s Situated Learning Theory [21] to examine how individual competency development interacted with workplace learning environments and broader organizational contexts. This theoretical interpretation facilitated a deeper understanding of the mechanisms influencing competency acquisition and maintenance beyond the descriptive synthesis of findings (Fig. 2). Summary tables were used to present study characteristics and synthesized findings. The final integrated synthesis highlights key patterns, identifies critical evidence gaps, and delineates implications for nursing policy, education, and clinical practice in Ghana.

Fig. 2.

Summary of study findings: using the integration of novice-to-expert & situated learning models

Results

Search results

Our initial search of electronic databases identified 379 articles published between 2000 and January 2026. After removing duplicates and conducting a preliminary screening, 267 articles were retained for title and abstract review based on predefined eligibility criteria. Of these, 245 articles were excluded because they did not meet the inclusion criteria, leaving 22 articles selected for full-text review. Following a full-text assessment, 10 studies were further excluded because they did not meet the inclusion criteria, including 5 with the wrong outcome, 2 with the wrong indicators, 2 with the wrong design, and 1 with the wrong setting. Ultimately, 12 studies met the inclusion criteria and were incorporated into the final review (see Fig. 1).

Study characteristics

All twelve studies included in this review were empirical. Five employed qualitative descriptive designs [19, 31–34], four used quantitative descriptive cross-sectional approaches [35–38], two adopted mixed-methods designs [39, 40], and one utilized a multi-method design [41]. All studies selected were published between 2015 and 2025. Collectively, the included studies represented a total of 2,662 participants. This comprised 770 (29%) nursing students enrolled in diploma or degree programmes in both public and private institutions [19, 31, 34, 36, 38, 39]; 1,570 (59%) clinical nurses with diploma, bachelor’s, or master’s degrees [33–35, 37, 40, 41]; and 310 (12%) nurse educators, including tutors in nursing training colleges and university lecturers [31–33, 35, 39]. Additionally, 10 (0.38%) participants were clinical nurse preceptors [31], and 2 (0.075%) were nurse managers [33]. Regarding study settings, four of the included studies were conducted exclusively in nursing training institutions [19, 33, 36, 39], encompassing a total of 25 institutions. Another four were carried out in health facilities [34, 37, 40, 41], involving 18 facilities. The remaining four studies were conducted across both nursing training institutions and health facilities [31, 32, 35, 38], covering a combined total of 34 facilities. In terms of geographic scope, seven studies were nationwide or multi-regional [19, 32–35, 39, 40], three were conducted in Northern Ghana [31, 38, 41], and two took place in the Greater Accra region [36, 37].

Quality appraisal results

Across the 12 included studies, the evidence base demonstrated several methodological strengths, including appropriate alignment between study designs and research questions, relevant sampling approaches, systematic data collection and analysis, and generally clear links between study methods and reported findings (Supplementary file 3). These strengths provided a sound basis for synthesizing evidence on barriers and facilitators to clinical competency acquisition and maintenance. Quantitative studies generally demonstrated appropriate measurement and statistical approaches, with some using random or census-based sampling and validated instruments [35–38]. However, limitations such as non-random convenience sampling and incomplete reporting of participant response rates introduced potential concerns about selection and nonresponse bias and may limit the generalizability of findings [35, 37]. Qualitative studies demonstrated consistent methodological rigor, particularly in purposeful sampling, in-depth data collection, systematic analysis, and clear links between findings and supporting participant accounts [19, 31–34]. These features strengthened confidence in the qualitative evidence.

Mixed-methods studies generally demonstrated acceptable methodological quality within their individual qualitative and quantitative components but shared a common limitation in integrating these components [39–41]. Although mixed-methods designs were clearly described, qualitative and quantitative findings were often presented separately, with limited examination of convergence, complementarity, or divergence. This limited integration reduces confidence in inferences that depend on the combined interpretation of qualitative and quantitative evidence. Thus, while the individual components provided useful evidence, conclusions based primarily on their integrated findings were interpreted more cautiously.

In summary, the principal strengths of the evidence base were methodological coherence, systematic data collection and analysis, and consistent rigor in the qualitative evidence. The main methodological weaknesses were sampling and reporting limitations in some quantitative studies and inadequate integration of qualitative and quantitative findings in mixed-methods studies. These limitations do not invalidate the evidence but may affect the generalizability and confidence of findings, particularly where conclusions were supported predominantly by studies with methodological weaknesses. Findings consistently supported by methodologically stronger evidence were interpreted with greater confidence, whereas findings derived mainly from studies with identified limitations were interpreted more cautiously. The quality appraisal therefore served to contextualize the strength and reliability of the synthesized evidence and inform interpretation of the review findings rather than to exclude or weight studies.

Barriers to the acquisition and maintenance of nursing competency

The most frequently cited barrier to the acquisition and maintenance of nursing competency, as reported in eleven studies, was the lack of structured support for on-the-job training [19, 31–35, 37–41]. Infrequent or absent in-service training limited opportunities for skill development and maintenance among nurses [32, 37, 41]. Some frontline nurses reported exclusion from available workshops that could have enhanced their knowledge [41], while preference was reportedly given to colleagues who did not work in frontline clinical settings. Among nursing students, limited structured clinical teaching and inadequate, inconsistent clinical mentorship during hospital placements resulted in insufficient clinical competence [19, 31, 34, 38], with some students expressing concern about graduating without the requisite skills. Additionally, limited clinical experience among nursing lecturers reduced their confidence and effectiveness in skills-based teaching [39].

Closely following the lack of structured on-the-job training support were staff shortages and workload pressures, reported in nine studies [19, 31–35, 37, 39, 40]. Limited numbers of preceptors and clinical staff, combined with high patient workloads, reduced the time available for supervision, practical teaching, and independent skills practice [19, 31, 33, 35, 39]. Consequently, students reported feeling unsupported and unable to perform key tasks proficiently [34, 35, 41].

Other frequently reported barriers to competency acquisition and maintenance included workplace and learning cultures, as well as unstandardized teaching and learning practices, each identified in eight studies [19, 31, 33–35, 38, 39, 41]. Some nurses demonstrated truancy, lack of seriousness, and limited engagement in clinical learning opportunities [34], while negative attitudes toward research and evidence-based practice hindered competency development, with some discouraging students from applying theory to clinical practice [35]. These challenges were reinforced by workplace cultures that favored routine practice over innovation and were characterized by bullying, humiliation, fear-inducing behaviors, and unsupportive or punitive leadership, which undermined confidence, discouraged error reporting, and negatively affected patient safety competencies [35]. Across nursing institutions, unsatisfactory clinical teaching methods, including reliance on lectures and slide presentations rather than hands-on demonstrations, limited pedagogical preparation among nurse educators, and the absence of standardized patient safety protocols contributed to misalignment between teaching, assessment, and clinical practice. These deficiencies resulted in greater reliance on personal judgment, inconsistent clinical practices, reduced adherence to evidence-based guidelines, weaker development of critical thinking and clinical reasoning skills, and an increased risk of preventable errors [19, 32, 33, 39, 41].

The lack of a structured national CPD and competency monitoring system was another key factor contributing to declining competency over time [19, 33, 35, 37, 39]. Limited enforcement of regulatory requirements for educators’ ongoing clinical practice resulted in competence gaps among nursing lecturers [39], with some demonstrating limited motivation to engage in continuous learning. Additionally, the absence of a standardized framework allowed some training institutions to prioritize theoretical instruction over practical competence [33], resulting in graduates completing their education without mastering essential clinical skills required for effective patient management.

Other reported barriers were poor collaboration between nursing colleges and clinical facilities [31, 32, 34, 38], limited managerial support [32, 40], disruption of learning due to service-oriented exploitation [32, 34], restrictive career advancement and study-leave policies [40, 41], and lower competence and skills acquisition in private institutions than public institutions [36].

Facilitators to the acquisition and maintenance of nursing competency

Conversely, several facilitators were identified as supporting competency and skills acquisition and maintenance. The most consistently cited facilitator was adequate time and support [19, 31, 34, 35, 37–41]. Regular, structured in-service training strengthened clinical competence [37, 41], while organizational support for professional development, such as study leave and scholarships, enhanced staff motivation and skills acquisition [37]. For students, supportive clinicians and preceptors who actively guided and mentored learners during clinical placements facilitated effective competency transfer [39]. Educators who provided hands-on exposure during clinical training enabled students to observe real-world practice and perform key nursing tasks proficiently [34].

Standardized teaching and learning practices or guidelines were also identified as vital facilitators [31–36, 38, 39, 41], ensuring that all nursing students are taught the same core knowledge and skills regardless of instructors or institutions. Adaptive teaching strategies, including improvisation and videography, were reported to mitigate resource limitations and promote students’ understanding of concepts [32]. Positive learner attitudes and supportive workplace cultures further facilitated competency development [32, 34, 38, 39, 41]. Welcoming clinical environments and positive staff attitudes promoted peer learning, mentorship, and confidence [39]. Furthermore, higher qualifications and longer clinical experience were also associated with greater competency [32, 36, 37, 39, 41]. Nurses with higher levels of education, particularly those who progressed from diploma to higher qualifications, demonstrated stronger competencies [41]. Similarly, nurses with more years of clinical experience exhibited higher levels of knowledge and skill than newly qualified staff, with senior nurses showing particularly high levels of professional competence [41].

Another important facilitator cited in the literature was resource availability [34, 37, 41]. Increased allocation of resources and policy prioritization for training and competency monitoring improved skill acquisition among nursing staff [41]. Adequate clinical resources, including well-equipped skills laboratories, provided safer environments for learning and practicing correct procedures compared to ward settings [34]. Finally, interdisciplinary collaboration between training institutions and healthcare facilities was identified as a key contributor to competency acquisition and maintenance [31, 32, 38]. Strong coordination and communication between these institutions improved support for student learning during clinical placements [31]. It also provided the opportunities for joint supervision, supporting safe clinical learning and ensuring that students practiced skills under guided oversight while minimizing patient harm [38].

Discussion

This review explored the barriers and facilitators to clinical competency acquisition and maintenance among nurses in Ghana. While the findings presented in this section highlight the most frequently cited barriers and facilitators across the included studies, it is important to recognize that their frequency should not overshadow the significance of less commonly reported, but equally impactful studies. Overall, the findings demonstrate that competency development is predominantly influenced by systemic and organizational factors rather than individual effort, with major constraints arising from weakly structured workplace training, inadequate continuing professional development systems, workforce shortages, unsupportive learning environments, inconsistent educational practices, and limited regulatory enforcement. Conversely, structured in-service training, standardized teaching and clinical guidelines, effective mentorship, supportive workplace cultures, higher educational attainment, and adequate resources emerged as critical enablers of sustained competence. Collectively, these findings reveal significant gaps in the integration of nursing education, clinical practice, and regulatory oversight, underscoring the need for coordinated, competency-driven reforms to strengthen nursing practice and patient care in Ghana.

A central finding was the limited availability and inconsistent implementation of structured on-the-job training and CPD. Instead of functioning as sustained mechanisms for reinforcing and updating clinical competencies, training and CPD activities were largely described as sporadic, unevenly accessible, and poorly integrated into routine clinical practice. When professional development is disconnected from everyday clinical practice, nurses may have fewer opportunities to build on prior experience and progressively strengthen their competence. Nurses with access to in-service training often gain current knowledge and new clinical perspectives that are not shared systematically with colleagues, creating disparities in practice and undermining team-wide consistency of care. Similar patterns have been documented in previous studies, which indicate that CPD is frequently weakened when treated as a compliance or credentialing requirement rather than as a continuous, practice-embedded learning process [43–45]. These findings highlight a critical gap between CPD policy intentions and operational realities in Ghana. For nursing practice, this gap has important implications, including skill decay, limited uptake of evidence-based interventions, and reduced adaptability to evolving clinical demands. Addressing these challenges requires the systematic integration of regular, hands-on in-service training into everyday clinical operations, positioning CPD as an ongoing professional responsibility rather than an episodic or administratively driven activity.

Workforce shortages and excessive workloads significantly undermine competency development by limiting opportunities for supervision, mentorship, and reflective practice. In overstretched clinical settings, nurses often must prioritize immediate patient care while also supervising students and supporting newly qualified colleagues, leaving insufficient time for structured guidance, skills coaching, and feedback. Novice nurses similarly face constrained transitional support, which can hinder confidence building, slow skill acquisition, and increase reliance on informal or unsupervised practice, potentially interrupting the progression from supported learning toward greater independence in practice. Evidence from Ethiopia and Namibia demonstrates strong associations between staffing levels, supervision quality, and nurses’ perceived clinical competence [2, 46, 47], underscoring the critical role of adequate staffing in effective clinical learning. When staffing levels are insufficient, clinical environments are unable to fulfil their dual mandate as sites of both service delivery and professional development. Addressing this gap requires coordinated workforce and education planning that formally integrates supervision and mentorship, particularly for students and early-career nurses, into routine nursing roles rather than treating them as optional or secondary responsibilities.

The review underscores the critical role of workplace culture and organizational leadership in shaping nurses’ competency acquisition and application. Clinical environments characterized by fear, intimidation, punitive leadership, and inadequate supervisory support suppress questioning, help-seeking, and reflective dialogue, all of which are fundamental to professional learning and skill consolidation. Within these environments, negative learner attitudes, including disengagement from clinical learning, reluctance to seek guidance, and limited engagement with evidence-based practice, may emerge as manifestations of unsupportive organizational cultures rather than solely individual characteristics. For novice and student nurses, these conditions contribute to fragmented learning experiences, reduced confidence, and limited integration of theoretical knowledge into clinical practice. Experienced nurses are similarly affected, as prolonged exposure to unsupportive workplace cultures can erode professional motivation, normalize task-oriented rather than reflective practice, and discourage participation in mentorship, supervision, and continuing professional development. Over time, these conditions contribute to stagnation in clinical competence and weaken professional role modeling. These findings align with qualitative studies showing that hostile clinical cultures widen the theory–practice gap and constrain nurses’ professional growth across career stages [48–50]. Strengthening workplace cultures through supportive leadership, psychologically safe learning environments, respectful supervision, and structured mentorship is therefore essential for promoting continuous competency development, professional confidence, and high-quality nursing practice.

Inconsistencies in teaching and assessment practices across nursing institutions further complicate nursing students’ competency development. Limited pedagogical preparation among nurse educators, coupled with heavy reliance on didactic instruction, restricts students’ opportunities to develop clinical reasoning, judgment, and decision-making skills through active, practice-oriented learning. Inconsistent assessment practices also create uncertainty about performance expectations, leaving students unclear about required competency standards and insufficiently prepared for clinical responsibilities. Evidence from studies among nursing students in Ethiopia and across sub-Saharan Africa similarly indicates that inadequate clinical teaching approaches and inconsistent supervision contribute to graduates entering practice with limited confidence and competence [51, 52]. Nursing curricula should therefore move beyond predominantly didactic instruction toward competency-based education that deliberately integrates simulation, structured clinical supervision, reflective practice, and workplace-based assessment. Competency portfolios and Objective Structured Clinical Examinations (OSCEs) could further provide systematic opportunities to document and assess the progressive development and application of clinical skills. For nursing schools and affiliated clinical training institutions, closer alignment of curriculum, clinical learning experiences, supervision, and competency assessment is essential to ensure that students graduate with demonstrable rather than primarily theoretical competence.

Regulatory and policy frameworks play a critical role in shaping how nursing competence is maintained over time. Although continuing professional development (CPD) is formally mandated, its weak linkage to demonstrated clinical proficiency limits its effectiveness as a regulatory mechanism for assuring ongoing competence. In practice, CPD participation is often assessed through attendance or credit accumulation rather than evidence of skill acquisition, application, or maintenance. These findings align with concerns raised in international nursing literature about the persistent disconnect between licensure renewal processes and actual clinical competence [53]. For nursing leadership and regulation, this underscores the need to move beyond attendance-based CPD toward competency-validated professional development models that prioritize demonstrated clinical proficiency, reflective practice, and accountability for performance in real clinical settings.

Despite the presence of multiple barriers, the review also identifies key facilitators that support the acquisition and sustained maintenance of nursing competence. These include adequate protected time for learning, organizational support, and access to structured mentorship. These facilitators are consistent with evidence highlighting the central role of mentorship and workplace-based learning in professional development [54–57]. Together, these conditions may support progressive development from guided learning toward greater confidence and independence in practice. However, their uneven availability across institutions points to variability in institutional commitment to learning-centered practice environments, with implications for equitable competency development across the nursing workforce.

Standardized teaching guidelines combined with adaptive instructional strategies also emerged as important enablers of competency development, particularly in resource-constrained settings. Innovative, low-cost approaches, such as equipment improvisation and the use of videography, were reported to mitigate gaps in material resources while enhancing conceptual understanding and skills acquisition among students. This finding highlights the potential for scaling contextually appropriate teaching innovations within nursing education systems. For educators and administrators, investing in standardized yet flexible teaching frameworks offers a pragmatic strategy for strengthening competency development while accommodating resource limitations.

In addition, positive learner attitudes, supportive workplace cultures, and peer learning were consistently associated with improved competency outcomes. Welcoming clinical environments fostered mentorship, confidence-building, and professional socialization, reinforcing the social and relational dimensions of learning emphasized in Situated Learning Theory. Nonetheless, the variability of such environments across clinical and educational settings underscores the need for deliberate cultivation of supportive cultures through leadership development, clear organizational policies, and accountability mechanisms. For nursing practice, intentionally fostering respectful, inclusive learning environments is essential for sustaining professional competence, reinforcing professional identity, and promoting workforce stability.

Recommendations for practice, education, and policy

The findings indicate that improving nurses’ clinical competency in Ghana requires coordinated action across education, clinical practice, organizational leadership, and professional regulation. Accordingly, competency development should be treated as a continuous process that begins with competency-based pre-service education and continues through structured workplace learning, supervision, continuing professional development, and ongoing competency assessment.

The Nursing and Midwifery Council of Ghana should strengthen competency-based regulation by establishing national competency standards and assessment guidelines and linking CPD requirements more closely to demonstrated clinical proficiency. Standardized preceptorship and clinical supervision frameworks should also be developed, with periodic competency revalidation considered as part of professional license renewal.

Within clinical and organizational settings, clinical preceptors and nurse managers should provide structured mentorship, regular feedback, and progressive opportunities for learners and early-career nurses to assume greater responsibility. Nurse managers should also protect time for learning and foster psychologically safe environments that encourage questioning, reflection, error reporting, and evidence-based practice. At the broader policy level, policymakers and other professional stakeholders should strengthen workforce and education policies that support lifelong competency development, including sustainable financing for continuing education, clinical training, and competency assessment. Coordinated implementation across regulatory bodies, educational institutions, and healthcare organizations will be essential to reduce fragmentation between nursing education and clinical practice and to sustain competency throughout nurses’ professional careers.

A focused research agenda should accompany these practice, educational, and policy efforts. Future research should prioritize national longitudinal studies examining competency development over time; randomized or quasi-experimental evaluations of competency-building interventions; validation of competency assessment tools for the Ghanaian context; implementation studies evaluating the effectiveness and sustainability of mentorship and preceptorship programs; economic evaluations of competency-based education and training; and national competency audits linked to quality-improvement initiatives. Together, these priorities would strengthen the evidence needed to determine which competency development strategies are effective, feasible, and sustainable within Ghana’s nursing education and healthcare systems.

Limitations of the study

Despite the valuable insights generated by this review, several limitations warrant consideration when interpreting the findings. First, the review included only peer-reviewed studies published in English and did not search grey literature. Consequently, relevant evidence from government and institutional sources, may have been missed, limiting the completeness of the evidence base.

Secondly, most included studies were also qualitative or cross-sectional, limiting insight into competency trajectories and longer-term intervention effects. Methodological heterogeneity across designs, populations, settings, and measures further limited direct comparison. The convergent integrated approach addressed this diversity by qualitizing quantitative findings and integrating them with qualitative evidence while preserving methodological distinctions; however, the synthesis should be understood as identifying patterns across diverse evidence rather than directly comparable estimates.

Finally, publication bias cannot be excluded, as studies reporting prominent barriers or facilitators may have been more likely to be published than studies with limited or inconclusive findings, potentially resulting in disproportionate representation of some factors in the synthesis. The findings should therefore be interpreted primarily within the Ghanaian nursing context, although many identified barriers and facilitators may also be relevant to countries with similar nursing education systems, regulatory structures, and resource constraints across sub-Saharan Africa and other LMICs.

Conclusion

This review identified organizational, educational, regulatory, and individual factors influencing the acquisition and maintenance of clinical competency among nurses in Ghana. Persistent challenges, including weakly structured CPD systems, workforce shortages, inconsistent teaching and assessment practices, and unsupportive learning environments, constrain sustained competency development. Addressing these challenges will require coordinated action among nurse educators, healthcare institutions, professional regulatory bodies, and policymakers, with emphasis on competency-based education, structured mentorship, practice-oriented CPD, supportive leadership, and robust competency assessment. Future research should prioritize longitudinal and intervention studies to determine how these competency-supportive strategies translate into sustained improvements in clinical performance and patient outcomes. Ultimately, implementing evidence-informed approaches to competency development can strengthen nursing education, enhance workforce capacity, improve patient safety, and support progress toward universal health coverage and more sustainable health systems in Ghana and other low- and middle-income countries.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

D.B.A. and E.W.V. conceptualized the study and wrote the manuscript. Y.F., R.A.A., S.S.D., E.S., B.L.A., and L.K. contributed to writing and reviewing the manuscript. A.A. supervised the study. All the authors reviewed and approved the final manuscript.

Funding

This study did not receive any funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interest

The authors declare no competing interests.