Content analysis of the Global Alliance for Nursing and Midwifery discussion forum: an online community of practice

Objective: to examine the usage and content of the Global Alliance for Nursing and Midwifery (GANM) discussion forum in relation to nursing and midwifery education and practice. Method: a qualitative conventional content analysis was performed. Subject lines from 1689 discussion board threads were extracted and used as the unit of analysis. A-priori codes were developed based on topical relevance (e.g. maternal health) and typical discussion board usage (e.g. announcing educational opportunities). Emerging codes were further identified while coding the data (e.g. infectious diseases). Results: the GANM discussion forum was used most frequently for information exchange (43.8%), such as dissemination of new information on evidence-based practice, and to announce educational opportunities (24.8%). The most frequently discussed topics were nursing (14.2%; e.g. the role of nurses in primary care, nursing education, etc.) and maternal health (13.8%; e.g. postpartum care, maternal mortality, etc.). Infectious diseases were discussed in 9% of threads, 40% of which concerned the current coronavirus pandemic. Conclusion: findings reinforce the utility of the GANM as a platform for professional development and continuing education. As a platform for disseminating empirical research, the GANM can be leveraged to have an influence on real-world, evidence-based practice.


Introduction
Given that 2020 is the year of the nurse and midwife, it is worth highlighting the importance of having a competent and educated workforce across different system levels and settings (1) . This entails providing the most up to date information pertaining to evidence-based practice and opportunities for continuous professional growth as means to build upon the competence of nurses and midwives globally (1) . Educational information exchange requires collaboration at the intra and interprofessional level to foster professional development and collaboration (1) .
These strategies for maximizing education in nursing and midwifery are essential for building competency and preparedness, especially in times of outbreaks such as the COVID-19 pandemic. According to Brand (2) , nurses are key players in a country's response to a national or international crisis. This means that they are not only providing care at the individual or population level, they are also improving health systems (2) . Thus, a commitment to continuous education is necessary to maximize the response of nurses in the face of a pandemic. To achieve such goals, an educational approach for a new infectious disease must address clinical knowledge, buildup of competencies, and accessibility to high quality, evidencebased material (2)(3) . Online communities of practice can serve as an essential tool to provide access to up to date resources to respond to healthcare needs for nurses and midwives globally (4)(5) . The GANM Knowledge Gateway supports a discussion board and an online library to provide a mechanism for knowledge dissemination globally. The discussion board serves as an online forum for sharing information and ideas, particularly related to nursing and midwifery.
What makes GANM's discussion forum unique is that it is moderated by graduate students at Johns Hopkins School of Nursing. Moderators perform supportive tasks such as providing help to members, as well as administrative tasks such as deleting spam (6) . Of relevance to the current study, all messages posted to the GANM discussion board must first be approved by a moderator. Nearly all messages were approved, with the exception of posts that were selling a product or contained inappropriate content.
The objective of this study was to examine the usage and content of the Global Alliance for Nursing and Midwifery (GANM) discussion forum in relation to nursing and midwifery education and practice.

Method
A qualitative content analysis was performed. This method was selected because it is commonly used in nursing studies and is a practical method for analyzing communication messages (7) . A qualitative approach was used to explore content areas discussed on the GANM discussion board. The content analysis is an appropriate methodology because it provides a "systematic and objective means of describing and quantifying phenomena" (8) . Using this approach, a priori codes were developed by the research team covering a range of maternal and child health topics and typical discussion Sixty-two percent of respondents identified English as their primary language, 29% identified Spanish, and 24% identified another language, with Portuguese, French, Nepali, Vietnamese and Arabic being the most common other languages spoken (9) .  were omitted, so any personal identifying information was removed for the analysis. The subject lines only were then copied into a separate Excel file, which was then imported into the qualitative data analysis software F4 Analyze.
F4 Analyze was used to facilitate data management and analysis. It was assumed that each subject line reflected the content of its corresponding thread, and was written in the same language.
Additionally, threads with 20 or more posts were reviewed to identify topics that generated the most participation. When GANM members participate in a conversation thread, each response is recorded as a post within the thread. This analysis was done because in the method described above, each thread is counted exactly once. By examining threads with greater than 20 posts we were able to identify specific topics of interest, creating a fuller picture of what GANM members choose to discuss and engage with on the discussion board. Coding moderator-generated threads separately allowed for the differentiation between conversations initiated by moderators and discussion board usage driven by members at large. Messages were also cross-coded to identify the language in which they were posted.
Emerging codes were further identified while coding the data. For example, many posts discussed infectious diseases, including HIV, Ebola, and COVID-19 (Topics that comprised less than 3% of the total discussion threads were coded under "other health topics."). Each subject line could have more than one code; for example, a subject line announcing a GANM blog post about nursing during COVID-19 written in Spanish was coded under "GANM," "nursing," "infectious diseases," and "Spanish." Additionally, subject lines that discussed health in a specific country or geographical region were coded under the corresponding WHO region: African Region (AFRO),
One research team member coded all of the data and conferred with the team where there was ambiguity to establish intercoder reliability. For example, threads about engaging men and boys in family planning were not initially coded under "maternal health" because they address male participation. However, after conferral, the authors decided that because these threads centered around family planning, "maternal health" was an appropriate code.
The study was exempted from IRB review; discussion posts were de-identified and analyzed anonymously.   The threads that generated the most discussion among members (greater than 20 posts) were entitled, "Doulas" (53 messages) and "Looking for collaborators"
A minority of threads were written in Spanish (13.5%). While a handful of subject lines were written in languages other than English or Spanish (notably,

Portuguese and French), these comprised a negligible
percentage of threads.

Discussion
The findings of this qualitative content analysis reinforce the utility of the GANM as a platform for professional development. Information exchange was shown to be a primary function of the discussion forum.
This is consistent with previous research findings that online discussion groups for health professionals are used more frequently for information sharing, communication, and networking (5) . With a global membership of over 4,000 practitioners, policymakers, researchers, and students the GANM forum is both an impactful and efficient vehicle for disseminating important information, including practice guidelines from the WHO and other international and professional organizations.
As a platform for disseminating empirical research, the GANM can be leveraged to have an influence on realworld, evidence-based practice. In particular, the GANM is used to share practice guidelines and professional competencies from international organizations, an important function of online communities of practice (4) . The ability to learn from other health professionals' experiences is also a valuable purpose of online communities as networking, knowledge sharing, and participation and interaction are initiated among participants (5,(10)(11) .
Opportunities for continuing education were plentiful and, due to the value that the nursing profession places on lifelong learning, significant. In addition to sharing as a dynamic process, collaborative learning, appropriate learning environment, and the act of seeking opportunities for learning (12)(13) . The discussion forum offers a means to implement lifelong learning by serving as an interactive space for members to access evidence-based information, ask questions, and share experiences, creating a dynamic learning environment and opportunities for collaboration.
By sharing article summaries of open access peer-reviewed empirical research hosted on the online community library, the GANM also offers opportunities for practitioners to actively seek out new knowledge.
With contributing members from over 60 countries, the GANM is an innovative platform for connecting practitioners worldwide for potential collaboration. This is most singularly exemplified by a post entitled, "Looking for collaborators", which generated over 50 responses.
The fact that a call for partnership garnered interest from members across the globe suggests that there is enthusiasm among members in using the GANM discussion forum for networking purposes. Indeed, previous research has shown that networking is a primary reason that health professionals use online discussion groups (5)   In light of the present COVID-19 pandemic, the ability to access reliable clinical knowledge is especially critical for nurses and midwives to maximize their impact of care.

Conclusion
Because of social distancing, it is even more critical to be able to access practice guidelines, training webinars, and evidence-based research articles from reputable sources online. Doing so allows nurses and midwives to build their competencies from the safety of their own homes while also slowing the spread of SARS-CoV-2.
The GANM discussion forum represents a transformative approach for knowledge acquisition during a global public health emergency with implications for nursing and midwifery practice. As a platform for disseminating empirical research, this low band-width technology offers nurses and midwives opportunities for professional growth that can have an impact on their realworld practice when caring for patients with COVID-19. www.eerp.usp.br/rlae