Nurses International’s Framework for Nursing Education in Low-Resource Countries.
Chickering, M.J., Spies, L.A., Keating, S.A. & Etcher, L.
Addressing community and population health needs in sub-Saharan East Africa was the impetus that sparked the creation of Nurses International. The World Health Organization estimates a current global shortage of 9 million nurses, with the shortage being most severe in developing countries where nurses are often the professionals charged, whether well-prepared or not, with meeting an estimated 80% of the health care needs of the population at large.
There is a tremendous need for well-educated healthcare providers who are prepared to meet the burgeoning health care needs that exist in low-resource countries. Mobilizing an international nurse faculty who are equipped to meet these needs through the provision of globally minded and locally relevant educational programs of excellence is a complex and challenging mission.
Nurses International has stepped forward to begin meeting this need, creating both a framework and educational methodology that, when applied, allows contextualization of program curriculum toward cultural relevance in any community. This multi-faceted framework and methodology have been specifically designed to foster the delivery of consistent, high quality and culturally relevant nursing education within low-resource countries.
Nurses International, a 501c3 organization, has currently developed an innovative and cutting edge Technology-Enhanced Classroom© and comprehensive BSN and MSN curriculum for nursing programs in low-resource countries. At Nurses International we believe that removing barriers to learning and increasing access to education, when combined with the provision of adequate resources, enables nursing students to focus on learning. Empowering these students through barrier removal and resource allocation promotes the development and growth of a supply of nurses who are prepared to take 21st Century nursing care to the local level in low-resource countries. The alleviation of suffering by these nurses will be the initial fruit and the starting impact: the potential that exists for blossomed transformation in terms of health and wellbeing of individuals, families, and communities touched by these nurses who graduate and then move to act within their communities and beyond is exciting to consider.
Listen, Learn, Serve, Share Framework
The Listen, Learn, Serve, Share model was developed by Nurses International and is used to identify barriers to and provide solutions for learning and health in a culturally appropriate, locally relevant context.
Commonly encountered barriers identified by the model have been found to include, among others, the following:
- Lack of qualified faculty
- Inadequate educational resources
- Prohibitive program costs
- Need for optimization of nursing roles and scope of practice
- Inaccurate public perceptions of professional nursing practice
The Listen, Learn, Serve, Share framework provides structure to the process of identifying the partner, student, and community strengths and needs. The LLSS Framework is key to properly augmenting strengths and to addressing needs toward the development of successful and sustainable collaborative partnerships. Nurses International applies the Listen, Learn, Serve, Share framework internally and promotes its use in cooperative endeavors.
Components of the Framework:
Listen: Listen to the stories, thoughts, insights and dreams of those with whom you are interacting.
Learn: Learn through the practice of cultural humility. Seek opportunities to engage as a learner with an open mind. Listening well reveals knowledge gaps and opportunities for learning and growth.
Serve: Serve by helping with partner identified immediate needs. Show that you care. As understanding, listening, and active learning occurs relationships become increasingly reciprocal. Serving to achieve mutually identified goals strengthens collaborative efforts.
Share: Identifying and sharing solutions is most effective when undertaken with an understanding of context, cultural knowledge, and collaborative service with partners. Solutions are best when they are shared with the community and sustainable within the community.
Listen, Learn, Serve, Share Application Exemplars
Collaborative engagement is an undergirding premise in the Listen, Learn, Serve, Share framework. Nurses International collaborates with organizations that have an existing nursing program or the infrastructure capable of facilitating a nursing program. Criteria for partnership considered include academic administrators, classrooms, and transportation for students to clinical sites. Preferred partners have demonstrated an ability to successfully collaborate with many organizations to achieve sustainable academic programs and community development initiatives.
Nurses International and its partners share core values of resilience, integrity, and a common vision of holistic, transformational community development. Partners also provide guidance regarding government accreditation requirements. The final goal is that in-country partners will take over ownership of the nursing program(s) that are initially a part of the shared endeavor with Nurses International.
Key partnership attributes:
- Shared vision
- Shared ownership
The Technology-Enhanced Classroom©
A Technology-Enhanced Classroom© (TEC) approach was developed initially by Nurses International in 2014 and has been refined since to effect removal of barriers to learning that are sustainable over time. The NI TEC approach brings groups of students together in a culturally typical model and augments classroom teaching with online content. To best employ technology, a learning management system with reverse syncing technology is used. The benefit of this approach is that it does not require sustained internet access. A generator or solar panel installation, a projector, and one laptop is the sum of hardware required to implement the curriculum. Using TEC as the interface, students are able to view course content and take assessments on tablets or even their phones. Local community-based nurses meet with students face-to-face in the classroom, serving as facilitators who come alongside students as mentors, to answer questions, and to lead learning activities
The reading materials, activities, lectures, and assessments, developed by faculty with content expertise, are loaded onto the learning management system platform. The digital curriculum can be accessed simultaneously in multiple classrooms thereby reducing costs. The shared content is collaboratively contextualized by the off-site faculty and the onsite facilitator.
The technology tools employed over the curriculum include:
● Learning Management Tool - iSpring Learn
● Authoring Tools - iSpring Suite, iSpring Free, iSpring Quiz Maker, Microsoft PowerPoint
● Communications - Microsoft 365 for faculty, staff, and mentors. Zoom Room for video conferencing.
Multinational Faculty - A Truly Global Effort
Nurses International volunteer faculty originate from many countries around the world. Exposure to nursing experts from different academic and practice settings provides students access to global expertise, diverse perspectives, and the breadth and depth of global nursing role models. Intentional professional socialization of nursing students occurs in the classroom with off-site faculty and on-site facilitators as well as in face-to-face interactions with faculty during clinical experiences. Creating a community of learning and caring is a top priority, and achieved through timely response to student questions, planned intermittent synchronous teaching sessions, online forums, and discussions. Students receive individualized and holistic attention throughout their course of study. The curriculum incorporates planned interactions between faculty and students using methods such as the inclusion of caring questions and responses.
Scope of nursing practice
The Nurses International Curriculum contains many activities and projects designed to develop students to the full extent of nursing practice, particularly in the roles of community/public health nurse and nurse educator. The BSN curriculum focuses on the preparation of nurses to practice in acute care settings and nurse-led clinics while the MSN curriculum, containing two tracks, focuses on the preparation of nurse educators and primary care nurses who can function in a role similar to that of a family nurse practitioner. The Technology-Enhanced Classroom ©, Nurses International’s diverse faculty, and a digital BSN and MSN curriculum eliminates many barriers and has great potential to build 21st-century nursing capacity in resource-poor countries.
Students are selected from applicants within the partner communities that meet mutually identified criteria. The targeted communities provide classrooms, clinical sites and a place for demonstration gardens. Students initiate projects, conduct research, and engage in planned clinical experiences within their sending communities. Students who agree to practice in their communities for a specified number of years will be prioritized to receive scholarships for continuing education as they are available. These scholarships help communities in need to develop a stable cadre of nurses who will remain within the community to practice, minimizing migration elsewhere.
Costs are kept low through the use of existing facilities, the Technology-Enhanced Classroom©, and volunteer faculty. However, there are administrative costs, the cost of the on-site facilitators, lab equipment, technology-related equipment, energy and transportation costs, equipment for students such as lab coats, stethoscopes, etc. The program's sustainability is enhanced when student fees are assessed on an income-based sliding scale. When enough graduates have completed the MSN in the education track and a specified number have obtained doctoral degrees, the spectrum of program metrics will have been met, and sustainability is then expected for the program. The ultimate goal will be realized when program graduates are practicing professionally at the highest level in the local setting, contributing to health policy, conducting research, publishing in peer-reviewed journals, writing textbooks, developing curriculum, and independently running nursing programs.
Nursing students in East Africa typically learn English in secondary school, often as a second or third language. The range of ability and comfort in English varies. Therefore, to assure student success, an eight-week intensive course in English prior to the start of the program will be required. Additional required English classes will run concurrently during the first year of the program. The on-site facilitators will be fluent in English as well as the student’s primary languages.
Nurses International shares its framework and tools with the hope that others interested in nursing education in low-resource countries can replicate and build upon the framework. Nurses International faculty and researchers will observe and collect data on the framework and curriculum, assessing effectiveness and targeting areas to improve during the pilot phase of the program.
The program will be dynamic, and faculty will use evidenced-based materials and knowledge acquired in the field for additional content creation. Once the framework has been adequately tested, refined, and finalized as workable within the domain of professional nursing education, next steps include the plan to extend the NI model to other professional domains and community needs.
As the program continues to emerge, develop, and grow, it is anticipated that findings from the pilot and subsequent work will serve to begin filling the gap that currently exists in terms of best practices around the development of sustainable educational initiatives in low-resource countries. Findings have the potential to inform future work by educational researchers and foster new interest in the area of developing sustainable educational initiatives in low-resource countries.