International Journal of Nursing Practice 2016; 22: 43– 52
CLINICAL PAPER
Bridging nursing practice and education through a strategic global partnership Marilyn Stringer PhD, CRNP, RDMS, FAAN Professor Emerita of Women’s Health Nursing, Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Lakshmi Rajeswaran PhD RN Lecturer in Nursing, School of Nursing, University of Botswana, Gaborone, Botswana
Kefalotse Dithole PM, RN, PhD (candidate) Lecturer in Nursing, School of Nursing, University of Botswana, Gaborone, Botswana
Linda Hoke PhD RN, CCNS, ACNS-BC, CCRN Clinical Nurse Specialist, Cardiac Intermediate Care Unit, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Patricia Mampane BSN, RN, RM Unit Manager, Infectious Diseases Care Clinic, Princess Marina Hospital, Gaborone, Botswana
Sheila Sebopelo BSN, RN Infection Control Officer, Nursing, Princess Marina Hospital, Gaborone, Botswana
Margret Molefe MSN, RN, RM Former Senior Nursing Officer, Ministry of Health, Gaborone, Botswana
Marjorie A Muecke PhD RN, FAAN Assistant Dean, Global Health Affairs, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA Associate Director, WHO Collaborating Center for Nursing & Midwifery Leadership, Philadelphia, Pennsylvania, USA
Victoria L Rich PhD RN, FAAN Chief Nurse Executive, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA Associate Professor, Nursing Administration, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Rosemary C Polomano PhD RN, FAAN Professor of Pain Practice, Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA Professor, Anesthesiology and Critical Care (Secondary), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
Accepted for publication June 2014
Correspondence: Rosemary C. Polomano, Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104, USA. Email: [email protected] doi:10.1111/ijn.12362
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Stringer M, Rajeswaran L, Dithole K, Hoke L, Mampane P, Sebopelo S, Molefe M, Muecke MA, Rich VL, Polomano RC. International Journal of Nursing Practice 2016; 22: 43– 52 Bridging nursing practice and education through a strategic global partnership To forge strong relationships among nurse scholars from the University of Pennsylvania School of Nursing, Philadelphia, PA (USA); University of Botswana School of Nursing, Gaborone, Botswana; the Hospital of the University of Pennsylvania, Philadelphia; Princess Marina Hospital (PMH), Gaborone; and the Ministry of Health of Botswana, a strategic global partnership was created to bridge nursing practice and education. This partnership focused on changing practice at PMH through the translation of new knowledge and evidence-based practice. Guided by the National Institutes of Health team science field guide, the conceptual implementation of this highly successful practice change initiative is described in detail, highlighting our strategies, challenges and continued collaboration for nurses to be leaders in improving health in Botswana. Key words: evidence- based practice, global partnerships, nursing education, nursing practice, team science.
INTRODUCTION Global nursing partnerships between countries with progressive health-care systems and developing countries are vitally important to advancing nursing science, education and practice, yet a recent review reports only 15 publications addressing such partnerships, with most focused on educational parterships.1 Many schools of nursing in the United States of America (USA) have established productive global health programmes demonstrating mutual benefits for students, clinicians and researchers.2–6 Clearly, methodologies and models for exemplary partnerships inform the global nursing community as to optimal ways to build capacity for sustaining lasting and impactful global relationships.3,7 Programmes that focus on developing global emerging leaders are especially valuable in transforming health care in sectors of the world. The University of Pennsylvania (UPenn) and the University of Botswana (UB) have had 10-year collaboration among several disciplines, focusing on building capacity to improve health outcomes in Botswana. For nursing, a partnership between the UPenn School of Nursing Dean and some faculty and UB’s Head of the Nursing School has existed for several years, with exchange programmes for Visiting Professorships; UPenn faculty providing research consultations in Botswana; and UB hosting UPenn students in community health. In 2008, nurse leaders and front-line care nurses from the Hospital of the University of Pennsylvania (HUP), Philadelphia, PA, USA, visited Princes Marina Hospital (PMH) in Gaborone, Botswana, to initiate foundational work to advance education and clinical practice. During this initial visit, trusting relationships were © 2014 Wiley Publishing Asia Pty Ltd
formed, and a mutual vision was set for PMH to begin its journey towards practice excellence, with the long-term goal of applying for the American Nurses Credentialing Center (ANCC) Pathways to Excellence® Program and eventually the Magnet Recognition Program® for designation of nursing and organizational excellence. The HUP team conducted comprehensive education in basic infection prevention and control practices, emergency responses to critical patient events, and principles of authentic leadership. Subsequently, another UPenn and HUP team visited Gaborone in 2009 to promote interdisciplinary evidence-based palliative care practice through a 5 day workshop.8
Challenges in health care at PMH and nursing education at the UB Botswana is a democratic county situated northwest of South Africa with a 2013 estimated population of 2 127 825.9 Since 2010, the Ministry of Health (MOH) assumes oversight for all health-care services in Botswana, including serving as the decision-making body for deciding employment settings for nurses within the health-care system. Professional nurses in Botswana do not always have the same opportunities as USA nurses in choosing their specialization in nursing or where they prefer to work. The state of nursing in Botswana is fully described in a comprehensive review that emphasizes the growing population health problems, notably a high prevalence of HIV/AIDS and current status of the nursing workforce, including a nursing shortage.10 As of 2006, the ratio of nurses was 28.8 per 100 000 people, which falls in the low range of 10 to 100 nurses per 100 000 people for
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developing countries.11 Not unique to Botswana, increased work demands are responsible for poor satisfaction among nurses in developing countries, but factors such as low status, limited autonomy and low pay are also associated with nurse dissatisfaction.12 PMH has over 550 beds; however, challenges in patient throughput related to delays with transitions in care and increasing patient volume often lead to a unpredictable fluctuating daily patient census exceeding bed capacity. This necessitates the placement of overflow beds, which results in changes in staffing and scheduling practices that all too frequently require nurses to care for greater numbers of patients. Botswana clinical nurses at PMH do have policies to guide their practices, but have fewer practice resources such as evidence-based practice (EBP) guidelines and limited access to research publications to guide independent and interprofessional decision-making. One goal of this project was to expand the clinical resources accessible to Botswana clinical nurses and to assist in the translation of EBP guidelines to clinical care. The historical background and current state of nursing education in Botswana are thoroughly discussed in a recent 2012 publication where it is reported that over 5 years, Botswana diploma schools have produced approximately 3000 graduates, whereas UB School of Nursing in Gaborone, the only school in Botswana offering a Bachelor’s degree, graduated around 80 to 100 nurses annually.13 UB has several graduate programmes in advanced practice nursing, and doctorally prepared faculty who actively pursue research to advance the science of nursing. UB faculty also supervise student clinical experiences at PMH. To expand a global nursing partnerships between UPenn and entities in Botswana, a grant-funded (UPenn Tiffany Foundation) project enabled work to forge strong relationships among nurse scholars from the UPenn School of Nursing, Philadelphia, PA (USA); UB School of Nursing, Gaborone, Botswana; the HUP, Philadelphia; PMH, Gaborone; and the MOH of Botswana. The primary aims of the project were to: (i) engage nurse scholars from education, research, practice and administration in work to advance the scientific foundations for EBP and research utilization at the PMH; (ii) align education with practice by preparing nursing faculty and practice leaders to collaborate in addressing health problems and issues of greatest concern to the well-being of the citizens of Botswana. Here, we present our experiences in forming and executing this strategic global partnership.
METHODS The UPenn-Botswana Nursing Team Collaboration Model was conceived through an interaction and integration model adapted from the Collaboration and Team Science: A Field Guide published by the National Institutes of Health, USA.14 This field guide served as the structural framework to assemble model components for practice, education, leadership and research, and direct processes for team building and accomplishing mutual goals. This team science collaboration incorporated the mission, vision and values from the UPenn and UB Schools of Nursing to engage global leaders in advancing the art and science of professional nursing and fostering strategic partnerships to propose and test solutions in response to the current challenges facing Botswana nursing practice leaders and faculty. Pressing issues for Botswana nurses centered on the delivery of quality and safe patient care through access to clinical resources to support practice (e.g. evidence-based guidelines and best practices), empowering nurses to engage in interprofessional collaboration as the basis for team-based care, and forming productive relationships between nursing practice leaders and faculty to bridge education and practice. By adapting and implementing the Collaboration and Team Science: A Field Guide, it was possible to devise a stepwise approach to accomplish work by the UPenn-Botswana nursing team: (i) planning stages for change; (ii) building a team of scholars (team selection and membership, fostering trust and ground rules); (iii) establishing a shared vision; (iv) navigating and leveraging networks and systems; (v) strengthening team dynamics; and (vi) addressing the challenges. Figure 1 shows the level of interactions in sequential phases of collaboration and team science.
Planning stages for change To expand the UPenn-Botswana collaboration, in early 2012 the head of the UB School of Nursing visited the UPenn School of Nursing as the Dean’s International Visiting Scholar. During her visit, a new direction for the inter-school partnership was defined that would promote intra-nursing collaboration across education, practice and policy in Botswana. The plan involved UPenn Nursing hosting five Botswana nurses from academia, practice and the government for a month-long immersion experience at UPenn for exposure to university nursing education and tertiary hospital health care. This experience would allow Botswana colleagues to chart their course for desired change in their academic and practice settings based on © 2014 Wiley Publishing Asia Pty Ltd
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Level of Interaction and Integration Low
High
Planning Stages for Change Febraury 2012 to October 2012
Building a Team and Establishing a Shared Vision April 2012 to May 2012
Building a Team of Scholars
Planning Establishing a Shared Vision
Botswana Scholars Visit UPenn June 2012 UPenn Faculty Visit Gaborone, Botswana September 17 to October 1, 2012
Navigating and Leveraging Networks, Systems Strengthening Team Dynamics
Addressing the Challenges
Figure 1. Phase-specific collaborative team model.
perceived priorities, available resources and feasibility of change. The head of the UB School of Nursing returned to Botswana to identify five nurse scholars to partner with UPenn faculty to advance this collaboration. The UPenn team subsequently secured an internal grant (UPenn Tiffany Foundation Grant) to accomplish and build a stronger strategic partnership with colleagues in Botswana. The grant supported a 4 week experience (June 2012) in the USA for five Botswana scholars and a 2 week visit (September 2012) to Botswana by three UPenn faculty. UPenn’s Nursing Global Health Affairs Office (Assistant Dean, author MAM) served as the administrator for the grant coordinating all travel and housing arrangements for the Botswana and UPenn teams, and orientation of Botswana visitors to UPenn.
Building a team of scholars Team selection and members
The UPenn-Botswana team included five Botswana nurse leaders selected for their ability to influence changes in education, practice and research. The team consisted of a PhD-prepared UB faculty member (author LR) and Masters-prepared PhD candidate faculty member (KD), two registered nurses (RNs) with administrative roles in patient safety from PMH (PM and SS) and the chief nurse for the Botswana Ministry of Health (MM). This was the first collaboration between these two UB faculty members and three nurse leaders from practice. The UPenn team consisted of three PhD-prepared nurses (MS, RCP, LH). MS and RCP are UPenn Standing Faculty-Clinician Educator (CE) Track and nurse scientists at the HUP, and © 2014 Wiley Publishing Asia Pty Ltd
both hold secondary appointments in departments at the UPenn Perelman School of Medicine. LH is a Clinical Nurse Specialist (CNS) whose primary appointment is at the HUP. The three UPenn and HUP nurse scholars were selected for their ability to influence practice, education and research across academic and clinical settings. Each has a strong background in cultivating successful collaborations among health-care professionals in practice and faculty.
Fostering trust and ground rules
The eight-member UPenn-Botswana team communicated through Skype calls from March to May 2012 to establish priorities for the month-long visit by Botswana colleagues in June 2012. As part of team building and mentoring, the UPenn faculty applied the Covey’s interdependence framework, which includes three concepts: (i) ‘Think Win-Win’, by striving for mutually beneficial solutions or agreements; (ii) ‘Seek First to Understand, Then to be Understood’, by creating an atmosphere of caring, empathic listening and positive problem -solving skills with an open mind and cultural sensitivity; and (iii) ‘Synergize’, by combining the strengths of the individual team members to achieve the goals no one person could have done alone.15 Managing conflicts and disagreements and keeping lines of communication open are essential for successful team building; therefore, the UPenn-Botswana team adapted a technique often used in health care known as ‘Crucial Conversations’, for conflict resolution.16 Preferences for how team members wanted to be acknowledged and credited for their work were discussed with
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Table 1 Key guiding principles in global nursing partnership teams to advance education and practice: lessons learned from the UPennBotswana collaboration Use a framework to guide collaboration to achieve mutual expectations and goals. • Select a framework that embraces structures, processes and outcomes. • Determine how the framework will support the collaboration. Engage the ‘right’ team members who are in the ‘right’ positions to influence change. Establish ‘ground rules’ for the partnerships: • Promote open and respectful communication. • Identify roles each team member will assume. • Agree on time commitments required to sustain the partnership and related work. • Consider preferences for how each entity and individuals wish to be recognized and credited for the work. • Apply communication principles such as ‘crucial conversation’ to keep lines of communication open and authentic. Set priorities of greatest need and interest to stakeholders to bring about change. Avoid imposing practices or cultural values that conflict with ‘norms’. • Be sensitive to the fact that the educational and clinical practices in one country might not be realistic, feasible or accepted in another country. • Allow global partners to experience the diverse educational and practice environments. • Tailor practice changes for the best chance of success. Develop and implement innovations that can be tested for scope of impact and value to promoting positive changes.
efforts to provide opportunities for both the Botswana and UPenn faculty to demonstrate global scholarship and build academic dossiers. Table 1 outlines key guiding principles implemented with our global nursing partnership.
Providing cultural experiences
Building a highly functioning global team requires dedicated work and recreation to provide opportunities to build caring, functional relationships. To cultivate cultural awareness and personal relationships, social activities were included such as shopping, dining at local eateries, and relaxing gatherings at UPenn and Botswana team member’s homes. In the USA, sightseeing trips to historic Philadelphia, New York City, and Washington DC were arranged for Botswana visitors. Although in Botswana, the UPenn team attended a traditional wedding reception and observed religious worship. The Botswana concept of ‘Botho’ was extended to the UPenn team with traditional cuisine, and visits to urban and rural attractions around Gaborone. In both countries, visiting teams had an insider’s view on health-care delivery.
Establishing a shared vision Guided by Donabedian’s model of structure process and outcomes,17 the UPenn-Botswana team collaborated over
a 2 month period with bi-monthly Skype calls to plan the 4-week immersion experience in the USA. A weekly schedule was created targeting content themes based on the Botswana team’s priorities for bringing about change in nursing education and practice, and fostering their professional and personal development. Week One: Teaching strategies and EBP Week Two: Palliative care and quality improvement Week Three: Learning strategies and peer review Week Four: Patient safety and project development Figure 2 highlights examples of structures, processes and outcomes for the UPenn immersion experience for Botswana scholars. Simultaneously, the team discussed how UPenn faculty would offer their expertise and provide mentorship in practice, education and research during their visit to Botswana in September 2012.
• • • •
Communicating about science
Communication around the scientific foundations for practice and education required a global perspective that encompassed internationally accepted EBP guidelines and best practices. Although advancements in these areas are known around the world, the UPenn-Botswana team examined relevant science that guides clinical care across the globe. It was particularly important to discuss bringing about changes in practice in Botswana by © 2014 Wiley Publishing Asia Pty Ltd
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Figure 2. Application of Donabedian’s model highlighting examples of the UPenn-Botswana partnership to meet identified priorities for changes in practice and education at PMH and UB. PMH, Princess Marina Hospital; UB, University of Botswana; UPenn, University of Pennsylvania.
carefully considering the translation of science into practice based on cultural values, feasibility, resources and acceptance of authoritative sources of scientific evidence by Botswana health-care providers. Global literaturebased methodologies and resources and recommendations were drawn from international professional organizations and societies.
Navigating and leveraging networks and systems Botswana colleagues’ visit to the UPenn
One lead UPenn team member assumed responsibility for coordinating all learning experiences for a given week, arranging for transportation, collecting and distributing scientific materials and other resources, and providing primary mentorship to the visiting scholar team. Experiences included classroom learning in both academic and clinical settings, daily team debriefing sessions, cultural experiences and collaborative team work to design a © 2014 Wiley Publishing Asia Pty Ltd
translational science project ready for implementation when Botswana scholars returned to Gaborone. Kirkpatrick’s Model of Learning Evaluation served as the framework for navigating and leveraging networks and systems for specific learning activities and methods of evaluation for the USA site visit18 (see Table 2). While in the USA, Botswana team members were all given access to UPenn’s library resources and training in conducting literature searches by a UPenn librarian. Each Botswana scholar received an iPad purchased through grant funds to retrieve and store electronic resources. On the academic side, Botswana scholars attended classes on research, women’s health and global health. Uniquely, they observed the three UPenn Standing-CE Track faculty (authors MS, RCP, VLR) bridge academia and practice in their professional roles. Opportunities were provided to meet with several UPenn faculty members who had visited Botswana and/or were engaged in ongoing research in Botswana to exchange
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Table 2 Adaptation of Kirkpatrick’s levels of learning evaluation13 Level Evaluation type Evaluation description and (what is measured) characteristics UPenn Experience for Botswana scholars 1 Reaction Reaction evaluation is how the delegates felt about the training or learning experience. 2 Learning Learning evaluation is the measurement of the increase in knowledge—before and after. Botswana scholars’ work behaviors upon return to Botswana: putting learning into action 3 Behaviour Behaviour evaluation is the extent of applied learning back on the job— implementation.
4
Results
Results evaluation is the effect on the business or environment by the trainee.
Examples of evaluation tools/methods
Relevance and practicability
Daily and weekly debriefing sessions Daily critiques of learning experiences Reflective learning Journaling
Learning experiences and practices were consistently evaluated for feasibility within the Botswana education and health-care system.
Botswana clinical nurses and nurse leaders: • Participated in interdisciplinary team meetings/rounds • Implemented new patient care practices post-surgical patients • Developed new documentation tools and evaluation of nursing care outcomes • Utilized the Rapid Results Methodology to bring about change in patient care.
Newly learned leadership and clinical practices were adapted to conform to cultural norms. New practices were trialled and evaluated by clinical staff. Realistic timelines were established to implement new patient care practices.
Newly integrated practices in the Botswana nurse scholars led an interdisciplinary team in care of surgical patients were implementing an Enhanced expanded to other patient populations and units. Recovery Critical Pathway for 45 adult male surgical patients over a 5 month period.
powerful stories about changes in the Botswana healthcare system. For clinical care at HUP, Botswana scholars spent time with nurse leaders, clinical educators and advanced practice registered nurses. They experienced several nursing leadership and interprofessional meetings to observe effective collaboration and communication. All Botswana visiting scholars spent time on patient care units witnessing first hand how HUP clinical nurses formulate plans of care, make autonomous clinical decisions, and collaborate with physicians and other health-care professionals in team-based care. Prevention strategies and monitoring of nursing-sensitive outcomes, along with best practices, centered on hospital-acquired pressure ulcers (HAPUs),
central line-associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Botswana scholars met with HUP EBP Committee members to discuss how projects are initiated and EBP guidelines influence care. To experience how nurses are empowered to direct and affect change through interprofessional collaboration, Botswana scholars attended Unit-based Clinical Leadership (UBCL) meetings where physicians, nurses and other care team members in leadership roles collaborate to share accountability for unit- and patient population-specific performance improvement outcomes. Every Friday, the Botswana team dedicated time to reflect on the week’s experiences, and observed © 2014 Wiley Publishing Asia Pty Ltd
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leadership, clinical and educational practices that could realistically be translated into their health care and academic settings as well as those that would not be feasible at the time. The UPenn-Botswana team also worked on the design of critical care pathway to structure and guide nursing care on the most challenging unit at PMH—the Male Surgical Ward (MSW). The team agreed on the Rapid Results Methodology or Initiative (RRI) (originally conceived in Africa) as the framework for the project to improve care for general surgery patients. The RRI methodology uses the progressive implementation of quality initiatives to bring about meaningful change in 100 days.19 A draft was assembled for an ‘Enhanced Recovery Surgical Critical Pathway’ with the intent of improving patient outcomes such as pain, nutrition and activity, and reducing the length of hospitalization for patients on the MSW from 7 to 10 days to 3 to 5 days. The pathway incorporated EBP guidelines for pain care, patient monitoring and other aspects of post-surgical care. At the completion of the month-long immersion experience, structures and processes were planned for a successful programme implementation in Botswana.
Botswana scholars return to Gaborone
Upon their return to PMH and UB, the Botswana team informed key stakeholders about their experiences in the USA, and shared educational and practice resources with colleagues. They engaged nurses, physicians, pharmacists and other health professionals and support service members in work to refine the critical pathway appropriate for the general surgical male population. The UPennBotswana team continued to engage in frequent Skype calls to seek approval of the critical pathway protocol by the PMH Ethics Committee, UB Institutional Review Board and MOH.
UPenn team visit to Botswana
Approximately two and half months following the return of the Botswana team to Gaborone, the three-member UPenn team (authors MS, RCP and LH) arrived in Gaborone to begin their 2 week immersion experience. It was evident that the Botswana team had already strengthened their relationships with officials from the MOH, the UB faculty leaders from the School of Nursing and Medicine, and nursing and physician leaders from PMH. The UPenn team went into action presenting over 15 in-service and grand rounds programmes for nurses and physicians and teaching in the school of nursing, reaching over 300 clinicians, faculty and students in total. © 2014 Wiley Publishing Asia Pty Ltd
To support practice and the implementation of the research-based ‘Enhanced Recovery Surgical Critical Pathway’, the UPenn-Botswana team collaborated with anaesthetists, surgeons and clinical nurses to develop a comprehensive post-surgical pain protocol that capitalized on evidence-based multi-modal analgesic strategies for aggressive pain control20,21 and EBP patient monitoring practices22 with broad applicability to various surgical populations. Importantly, this protocol used the RADAR approach (Responsibility, Anticipation, Discussion, Assessment and Response) to promote interdisciplinary pain care and underscore that pain management should be on everyone’s radar.23 Approximately 75 international and USA EPB guidelines, research publications and review articles were compiled to support clinical decisionmaking in post-surgical care. An all-day workshop sponsored by the MOH for 37 area nursing leaders and educators was held to highlight the critical pathway project and to teach aspects of practice leadership for achieving excellence in clinical care. While In Botswana, the UPenn team visited various facilities such as health clinics, a health post and a remote mobile stop where Botswana nurses work to experience the transitions in levels of care.
Strengthening team dynamics The initial time invested in strategic global planning was successful in strengthening team dynamics over time. This strategy of methodical planning, team building, and use of frameworks and models to explicate the strategic work and its evaluation proved invaluable in achieving strategic goals. Now separated by over 7000 miles, the UPennBotswana team continues to communicate regularly by Skype to complete the Enhanced Recovery Surgical Critical Pathway Project and discuss new opportunities for advancing the scientific foundations for nursing education and practice.
DISCUSSION—ADDRESSING THE CHALLENGES The UPenn-Botswana Nursing Collaboration is an expansion of a strong existing partnership that has enabled student experiences, faculty research and collaborations among academic leaders. However, our collaboration involved a new team of emerging leaders in Botswana and UPenn nursing faculty, and this specific collaboration spanned practice, education and research training. Our challenges were not unique in initiating a productive
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partnership; however, our initial planning addressed one important challenge. To be successful in endeavours to change practice through the translation of new knowledge and EBP guidelines in developing countries, representatives from these countries need to experience practice environments that successfully accomplish these challenges, and have time to assimilate these experience. As such, the immersion experience at UPenn allowed our Botswana team to determine the feasibility of adopting changes in practice and prioritize those having the greatest impact on the health and well-being of their patient populations. Moreover, when USA representatives visit developing countries to influence change, they can be more prepared and focused if they, too, have an a priori understanding of the current health-care challenges. Others have emphasized the importance of identifying specific needs, developing strong and sustained partnerships, and addressing barriers by creating and trialling effective solutions to ongoing challenges.24 The National Institutes of Health team science field guide with a team science focus was extremely beneficial in streamlining our work. Other models served as the foundational frameworks for planning and organizing the course of action and defining measureable outcomes for an integrative approach embracing training in practice, education and research. Model-driven global partnerships incorporating team science must account for a universal understanding of the contextual interpretations, and this includes team science. Stokols et al.25 provide an excellent analysis of the contextual influences on transdisciplinary collaboration with team science, and we found this especially useful in our efforts to engage physicians and other health-care professionals at PMH and UB in the critical pathway research project for male surgical patients. Interestingly, they emphasized the importance of measuring the effects of every team science interdisciplinary encounter. As an example, during an interdisciplinary team meeting at PMH, the UPenn-Botswana team discussed the scientific basis for interventions to prevent surgical complications, especially the need for early mobilization. Patients on the PMH MSW often remained in bed sometimes way beyond 24 h following surgery. The next day, several chairs were delivered to the ward as a result of actions taken by one of the PMH surgeons. In response to another interdisciplinary encounter underscoring the need for pain reduction strategies with multimodal analgesia, a pharmacist took measures to increase the availability of specific analgesics.
Other challenges not often easily managed were issues related to resource allocation for implementing EBPs in a developing country. For example, the pain protocol for post-surgical patients had to be adjusted to include analgesic agents that were available and accessible. Opioid-based regimens for pain control on general care wards could not be maximized due to the lack of opioid medications. The UPenn team remained sensitive to these issues, and attempted to introduce EBP guidelines, research-based practices and clinical support tools that were universally accepted throughout the world and not just those unique to the USA. At times, language barriers presented a challenge as meanings were lost in translation. Distance communication was difficult, with disruptions in Internet connections and email. Compensated faculty and clinician efforts at UPenn, PMH and UB were especially problematic as this effort required the dedicated work of many individuals, including clinical nurses whose work demands were increased as a result of our project for surgical patients. Often, lead UB nursing faculty researchers and PMH leaders had to assume additional responsibilities in the clinical care. The success of implementing a new evidence-based care pathway for surgical patients at PMH and the engagement of an interdisciplinary care team made this experience a most rewarding one.
ACKNOWLEDGEMENTS This collaboration was partially supported by funding from the University of Pennsylvania (UPenn) Tiffany Foundation Grant and in-kind support from UPenn, UB, PMH and the Botswana Ministry of Health. The authors wish to express their gratitude to Afaf I. Meleis, PhD, DrPS(hon), FAAN, Margaret Bond Simon Dean of Nursing, UPenn School of Nursing, Motshedises Sabone, PhD, RN, Head of the UB School of Nursing, and Harvey Friedman, MD, Director of the Botswana-UPenn Partnership and Professor of Medicine, UPenn Perelman School of Medicine for their continued support for the UPenn-Botswana Nursing Collaborative. A special thanks to Geralyn Grosso for all her efforts in supporting the logistics of this global partnership.
REFERENCES 1 George EK, Meadows-Oliver M. Searching for collaboration in international nursing partnerships: A literature review. International Nursing Review 2013; 60: 31–36. 2 Harper DC, Davey KS, Fordham PN. Leadership lessons in global nursing and health from the nightingale letter © 2014 Wiley Publishing Asia Pty Ltd
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3
4
5
6
7
8
9
10 11 12 13
collection at the University of Alabama at Birmingham. Journal of Holistic Nursing 2014; 32: 44–53. Vermund SH, Sahasrabuddhe VV, Khedkar S, Jia Y, Etherington C, Vergara A. Building global health through a center-without-walls: The Vanderbilt Institute for Global Health. Academic Medicine 2008; 83: 154–164. Koplan JP, Baggett RL. The Emory Global Health Institute: Developing partnerships to improve health through research, training, and service. Academic Medicine 2008; 83: 128–133. Bosworth TL, Haloburdo EP, Hetrick C, Patchett K, Thompson MA, Welch M. International partnerships to promote quality care: Faculty groundwork, student projects, and outcomes. Journal of Continuing Education in Nursing 2006; 37: 32–38. Lasater K, Upvall M, Nielsen A, Prak M, Ptachcinski R. Global partnerships for professional development: A Cambodian exemplar. Journal of Professional Nursing 2012; 28: 62–68. Powell DL, Gilliss CL, Hewitt HH, Flint EP. Application of a partnership model for transformative and sustainable international development. Public Health Nursing 2010; 27: 54–70. Ersek M, Sebego M, Bloom AM, Shaibu S, McMenamin E, Mokotedi M. Development and evaluation of an international, interdisciplinary palliative care workshop in Botswana. International Journal of Palliative Nursing 2010; 16: 13–21. Central Intelligence Agency. The World Factbook. 2013. Available from URL: https://www.cia.gov/library/ publications/the-world-factbook/fields/2119.html. Accessed 1 March 2014. Sinha N, Onyyatsteng G. The nursing labour market in Botswana: An economic analysis. PULA: Botswana Journal of African Studies 2102; 26: 109–124. World Health Organization. World Health Statistics 2012. Geneva: World Health Organization, 2012. Mrayyan MT. Jordanian nurse’s job satisfaction, patients’ satisfaction and quality of nursing care. International Nursing Review 2006; 53: 224–230. Seboni NM. Chapter 2: Botwsana. In: Klopper HC, Uys LR (eds). The State of Nursing and Nursing Education in Africa: A Country-By-Country Review. Indianapolis, IN: Sigma Theta Tau International, 2013; 25–40.
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14 Bennett L, Gadlin H, Levine-Finley S. Collaboration and Team Science: A Field Guide. Bethesda: National Institutes of Health, 2010. 15 Covey S. The Seven Habits of Highly Effective People. New York: Free Press, 2004. 16 Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations Tools for Talking When Stakes are High, 2nd edn. New York: McGraw-Hill, 2011. 17 Donabedian A. Evaluating the quality of medical care. The Milbank Quarterly 2005; 83: 691–729. 18 Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels, 3rd edn. San Francisco, CA: Berrett Koehler Publishers Inc, 1994. 19 Sylvester O. Rapid Results Approach / Initiative: Institutionalization of Results Based Management in Kenya Public Service. Available from URL: http://www.capam.org/ _documents/rapidresultsapproach.kenya.pdf. Accessed 20 June 2013. 20 Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet 2006; 367: 1618– 1625. 21 Macintyre PE, Scott DA, Schug SA, Visser EJ, Walker SM (eds.). Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine: Acute Pain Management Scientific Evidence (3rd ed.). 2010. Available from URL: http://www.anzca.edu.au/resources/college-publications/ pdfs/Acute%20Pain%20Management/books-andpublications/acutepain.pdf. Accessed 10 August 2013. 22 Jarzyna D, Jungquist CR, Pasero C et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing 2011; 12: 118–145. 23 Vickers A, Bali S, Baxter A et al. Consensus statement on the anticipation and prevention of acute postoperative pain: Multidisciplinary RADAR approach. Current Medical Research and Opinion 2009; 25: 2557–2569. 24 Rybak N, Koster M, Gilbert EB, Flanigan T. Building international collaborations from the ground up: Brown university partnerships in Haiti and Ukraine. Rhode Island Medical Journal 2013; 96: 33–37. 25 Stokols D, Hall KL, Taylor BK, Moser RP. The science of team science: Overview of the field and introduction to the supplement. American Journal of Preventive Medicine 2008; 35 (2S): S77–S89.
CLINICAL PAPER
Bridging nursing practice and education through a strategic global partnership Marilyn Stringer PhD, CRNP, RDMS, FAAN Professor Emerita of Women’s Health Nursing, Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Lakshmi Rajeswaran PhD RN Lecturer in Nursing, School of Nursing, University of Botswana, Gaborone, Botswana
Kefalotse Dithole PM, RN, PhD (candidate) Lecturer in Nursing, School of Nursing, University of Botswana, Gaborone, Botswana
Linda Hoke PhD RN, CCNS, ACNS-BC, CCRN Clinical Nurse Specialist, Cardiac Intermediate Care Unit, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Patricia Mampane BSN, RN, RM Unit Manager, Infectious Diseases Care Clinic, Princess Marina Hospital, Gaborone, Botswana
Sheila Sebopelo BSN, RN Infection Control Officer, Nursing, Princess Marina Hospital, Gaborone, Botswana
Margret Molefe MSN, RN, RM Former Senior Nursing Officer, Ministry of Health, Gaborone, Botswana
Marjorie A Muecke PhD RN, FAAN Assistant Dean, Global Health Affairs, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA Associate Director, WHO Collaborating Center for Nursing & Midwifery Leadership, Philadelphia, Pennsylvania, USA
Victoria L Rich PhD RN, FAAN Chief Nurse Executive, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA Associate Professor, Nursing Administration, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Rosemary C Polomano PhD RN, FAAN Professor of Pain Practice, Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA Professor, Anesthesiology and Critical Care (Secondary), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
Accepted for publication June 2014
Correspondence: Rosemary C. Polomano, Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104, USA. Email: [email protected] doi:10.1111/ijn.12362
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Stringer M, Rajeswaran L, Dithole K, Hoke L, Mampane P, Sebopelo S, Molefe M, Muecke MA, Rich VL, Polomano RC. International Journal of Nursing Practice 2016; 22: 43– 52 Bridging nursing practice and education through a strategic global partnership To forge strong relationships among nurse scholars from the University of Pennsylvania School of Nursing, Philadelphia, PA (USA); University of Botswana School of Nursing, Gaborone, Botswana; the Hospital of the University of Pennsylvania, Philadelphia; Princess Marina Hospital (PMH), Gaborone; and the Ministry of Health of Botswana, a strategic global partnership was created to bridge nursing practice and education. This partnership focused on changing practice at PMH through the translation of new knowledge and evidence-based practice. Guided by the National Institutes of Health team science field guide, the conceptual implementation of this highly successful practice change initiative is described in detail, highlighting our strategies, challenges and continued collaboration for nurses to be leaders in improving health in Botswana. Key words: evidence- based practice, global partnerships, nursing education, nursing practice, team science.
INTRODUCTION Global nursing partnerships between countries with progressive health-care systems and developing countries are vitally important to advancing nursing science, education and practice, yet a recent review reports only 15 publications addressing such partnerships, with most focused on educational parterships.1 Many schools of nursing in the United States of America (USA) have established productive global health programmes demonstrating mutual benefits for students, clinicians and researchers.2–6 Clearly, methodologies and models for exemplary partnerships inform the global nursing community as to optimal ways to build capacity for sustaining lasting and impactful global relationships.3,7 Programmes that focus on developing global emerging leaders are especially valuable in transforming health care in sectors of the world. The University of Pennsylvania (UPenn) and the University of Botswana (UB) have had 10-year collaboration among several disciplines, focusing on building capacity to improve health outcomes in Botswana. For nursing, a partnership between the UPenn School of Nursing Dean and some faculty and UB’s Head of the Nursing School has existed for several years, with exchange programmes for Visiting Professorships; UPenn faculty providing research consultations in Botswana; and UB hosting UPenn students in community health. In 2008, nurse leaders and front-line care nurses from the Hospital of the University of Pennsylvania (HUP), Philadelphia, PA, USA, visited Princes Marina Hospital (PMH) in Gaborone, Botswana, to initiate foundational work to advance education and clinical practice. During this initial visit, trusting relationships were © 2014 Wiley Publishing Asia Pty Ltd
formed, and a mutual vision was set for PMH to begin its journey towards practice excellence, with the long-term goal of applying for the American Nurses Credentialing Center (ANCC) Pathways to Excellence® Program and eventually the Magnet Recognition Program® for designation of nursing and organizational excellence. The HUP team conducted comprehensive education in basic infection prevention and control practices, emergency responses to critical patient events, and principles of authentic leadership. Subsequently, another UPenn and HUP team visited Gaborone in 2009 to promote interdisciplinary evidence-based palliative care practice through a 5 day workshop.8
Challenges in health care at PMH and nursing education at the UB Botswana is a democratic county situated northwest of South Africa with a 2013 estimated population of 2 127 825.9 Since 2010, the Ministry of Health (MOH) assumes oversight for all health-care services in Botswana, including serving as the decision-making body for deciding employment settings for nurses within the health-care system. Professional nurses in Botswana do not always have the same opportunities as USA nurses in choosing their specialization in nursing or where they prefer to work. The state of nursing in Botswana is fully described in a comprehensive review that emphasizes the growing population health problems, notably a high prevalence of HIV/AIDS and current status of the nursing workforce, including a nursing shortage.10 As of 2006, the ratio of nurses was 28.8 per 100 000 people, which falls in the low range of 10 to 100 nurses per 100 000 people for
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developing countries.11 Not unique to Botswana, increased work demands are responsible for poor satisfaction among nurses in developing countries, but factors such as low status, limited autonomy and low pay are also associated with nurse dissatisfaction.12 PMH has over 550 beds; however, challenges in patient throughput related to delays with transitions in care and increasing patient volume often lead to a unpredictable fluctuating daily patient census exceeding bed capacity. This necessitates the placement of overflow beds, which results in changes in staffing and scheduling practices that all too frequently require nurses to care for greater numbers of patients. Botswana clinical nurses at PMH do have policies to guide their practices, but have fewer practice resources such as evidence-based practice (EBP) guidelines and limited access to research publications to guide independent and interprofessional decision-making. One goal of this project was to expand the clinical resources accessible to Botswana clinical nurses and to assist in the translation of EBP guidelines to clinical care. The historical background and current state of nursing education in Botswana are thoroughly discussed in a recent 2012 publication where it is reported that over 5 years, Botswana diploma schools have produced approximately 3000 graduates, whereas UB School of Nursing in Gaborone, the only school in Botswana offering a Bachelor’s degree, graduated around 80 to 100 nurses annually.13 UB has several graduate programmes in advanced practice nursing, and doctorally prepared faculty who actively pursue research to advance the science of nursing. UB faculty also supervise student clinical experiences at PMH. To expand a global nursing partnerships between UPenn and entities in Botswana, a grant-funded (UPenn Tiffany Foundation) project enabled work to forge strong relationships among nurse scholars from the UPenn School of Nursing, Philadelphia, PA (USA); UB School of Nursing, Gaborone, Botswana; the HUP, Philadelphia; PMH, Gaborone; and the MOH of Botswana. The primary aims of the project were to: (i) engage nurse scholars from education, research, practice and administration in work to advance the scientific foundations for EBP and research utilization at the PMH; (ii) align education with practice by preparing nursing faculty and practice leaders to collaborate in addressing health problems and issues of greatest concern to the well-being of the citizens of Botswana. Here, we present our experiences in forming and executing this strategic global partnership.
METHODS The UPenn-Botswana Nursing Team Collaboration Model was conceived through an interaction and integration model adapted from the Collaboration and Team Science: A Field Guide published by the National Institutes of Health, USA.14 This field guide served as the structural framework to assemble model components for practice, education, leadership and research, and direct processes for team building and accomplishing mutual goals. This team science collaboration incorporated the mission, vision and values from the UPenn and UB Schools of Nursing to engage global leaders in advancing the art and science of professional nursing and fostering strategic partnerships to propose and test solutions in response to the current challenges facing Botswana nursing practice leaders and faculty. Pressing issues for Botswana nurses centered on the delivery of quality and safe patient care through access to clinical resources to support practice (e.g. evidence-based guidelines and best practices), empowering nurses to engage in interprofessional collaboration as the basis for team-based care, and forming productive relationships between nursing practice leaders and faculty to bridge education and practice. By adapting and implementing the Collaboration and Team Science: A Field Guide, it was possible to devise a stepwise approach to accomplish work by the UPenn-Botswana nursing team: (i) planning stages for change; (ii) building a team of scholars (team selection and membership, fostering trust and ground rules); (iii) establishing a shared vision; (iv) navigating and leveraging networks and systems; (v) strengthening team dynamics; and (vi) addressing the challenges. Figure 1 shows the level of interactions in sequential phases of collaboration and team science.
Planning stages for change To expand the UPenn-Botswana collaboration, in early 2012 the head of the UB School of Nursing visited the UPenn School of Nursing as the Dean’s International Visiting Scholar. During her visit, a new direction for the inter-school partnership was defined that would promote intra-nursing collaboration across education, practice and policy in Botswana. The plan involved UPenn Nursing hosting five Botswana nurses from academia, practice and the government for a month-long immersion experience at UPenn for exposure to university nursing education and tertiary hospital health care. This experience would allow Botswana colleagues to chart their course for desired change in their academic and practice settings based on © 2014 Wiley Publishing Asia Pty Ltd
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Level of Interaction and Integration Low
High
Planning Stages for Change Febraury 2012 to October 2012
Building a Team and Establishing a Shared Vision April 2012 to May 2012
Building a Team of Scholars
Planning Establishing a Shared Vision
Botswana Scholars Visit UPenn June 2012 UPenn Faculty Visit Gaborone, Botswana September 17 to October 1, 2012
Navigating and Leveraging Networks, Systems Strengthening Team Dynamics
Addressing the Challenges
Figure 1. Phase-specific collaborative team model.
perceived priorities, available resources and feasibility of change. The head of the UB School of Nursing returned to Botswana to identify five nurse scholars to partner with UPenn faculty to advance this collaboration. The UPenn team subsequently secured an internal grant (UPenn Tiffany Foundation Grant) to accomplish and build a stronger strategic partnership with colleagues in Botswana. The grant supported a 4 week experience (June 2012) in the USA for five Botswana scholars and a 2 week visit (September 2012) to Botswana by three UPenn faculty. UPenn’s Nursing Global Health Affairs Office (Assistant Dean, author MAM) served as the administrator for the grant coordinating all travel and housing arrangements for the Botswana and UPenn teams, and orientation of Botswana visitors to UPenn.
Building a team of scholars Team selection and members
The UPenn-Botswana team included five Botswana nurse leaders selected for their ability to influence changes in education, practice and research. The team consisted of a PhD-prepared UB faculty member (author LR) and Masters-prepared PhD candidate faculty member (KD), two registered nurses (RNs) with administrative roles in patient safety from PMH (PM and SS) and the chief nurse for the Botswana Ministry of Health (MM). This was the first collaboration between these two UB faculty members and three nurse leaders from practice. The UPenn team consisted of three PhD-prepared nurses (MS, RCP, LH). MS and RCP are UPenn Standing Faculty-Clinician Educator (CE) Track and nurse scientists at the HUP, and © 2014 Wiley Publishing Asia Pty Ltd
both hold secondary appointments in departments at the UPenn Perelman School of Medicine. LH is a Clinical Nurse Specialist (CNS) whose primary appointment is at the HUP. The three UPenn and HUP nurse scholars were selected for their ability to influence practice, education and research across academic and clinical settings. Each has a strong background in cultivating successful collaborations among health-care professionals in practice and faculty.
Fostering trust and ground rules
The eight-member UPenn-Botswana team communicated through Skype calls from March to May 2012 to establish priorities for the month-long visit by Botswana colleagues in June 2012. As part of team building and mentoring, the UPenn faculty applied the Covey’s interdependence framework, which includes three concepts: (i) ‘Think Win-Win’, by striving for mutually beneficial solutions or agreements; (ii) ‘Seek First to Understand, Then to be Understood’, by creating an atmosphere of caring, empathic listening and positive problem -solving skills with an open mind and cultural sensitivity; and (iii) ‘Synergize’, by combining the strengths of the individual team members to achieve the goals no one person could have done alone.15 Managing conflicts and disagreements and keeping lines of communication open are essential for successful team building; therefore, the UPenn-Botswana team adapted a technique often used in health care known as ‘Crucial Conversations’, for conflict resolution.16 Preferences for how team members wanted to be acknowledged and credited for their work were discussed with
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Table 1 Key guiding principles in global nursing partnership teams to advance education and practice: lessons learned from the UPennBotswana collaboration Use a framework to guide collaboration to achieve mutual expectations and goals. • Select a framework that embraces structures, processes and outcomes. • Determine how the framework will support the collaboration. Engage the ‘right’ team members who are in the ‘right’ positions to influence change. Establish ‘ground rules’ for the partnerships: • Promote open and respectful communication. • Identify roles each team member will assume. • Agree on time commitments required to sustain the partnership and related work. • Consider preferences for how each entity and individuals wish to be recognized and credited for the work. • Apply communication principles such as ‘crucial conversation’ to keep lines of communication open and authentic. Set priorities of greatest need and interest to stakeholders to bring about change. Avoid imposing practices or cultural values that conflict with ‘norms’. • Be sensitive to the fact that the educational and clinical practices in one country might not be realistic, feasible or accepted in another country. • Allow global partners to experience the diverse educational and practice environments. • Tailor practice changes for the best chance of success. Develop and implement innovations that can be tested for scope of impact and value to promoting positive changes.
efforts to provide opportunities for both the Botswana and UPenn faculty to demonstrate global scholarship and build academic dossiers. Table 1 outlines key guiding principles implemented with our global nursing partnership.
Providing cultural experiences
Building a highly functioning global team requires dedicated work and recreation to provide opportunities to build caring, functional relationships. To cultivate cultural awareness and personal relationships, social activities were included such as shopping, dining at local eateries, and relaxing gatherings at UPenn and Botswana team member’s homes. In the USA, sightseeing trips to historic Philadelphia, New York City, and Washington DC were arranged for Botswana visitors. Although in Botswana, the UPenn team attended a traditional wedding reception and observed religious worship. The Botswana concept of ‘Botho’ was extended to the UPenn team with traditional cuisine, and visits to urban and rural attractions around Gaborone. In both countries, visiting teams had an insider’s view on health-care delivery.
Establishing a shared vision Guided by Donabedian’s model of structure process and outcomes,17 the UPenn-Botswana team collaborated over
a 2 month period with bi-monthly Skype calls to plan the 4-week immersion experience in the USA. A weekly schedule was created targeting content themes based on the Botswana team’s priorities for bringing about change in nursing education and practice, and fostering their professional and personal development. Week One: Teaching strategies and EBP Week Two: Palliative care and quality improvement Week Three: Learning strategies and peer review Week Four: Patient safety and project development Figure 2 highlights examples of structures, processes and outcomes for the UPenn immersion experience for Botswana scholars. Simultaneously, the team discussed how UPenn faculty would offer their expertise and provide mentorship in practice, education and research during their visit to Botswana in September 2012.
• • • •
Communicating about science
Communication around the scientific foundations for practice and education required a global perspective that encompassed internationally accepted EBP guidelines and best practices. Although advancements in these areas are known around the world, the UPenn-Botswana team examined relevant science that guides clinical care across the globe. It was particularly important to discuss bringing about changes in practice in Botswana by © 2014 Wiley Publishing Asia Pty Ltd
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Figure 2. Application of Donabedian’s model highlighting examples of the UPenn-Botswana partnership to meet identified priorities for changes in practice and education at PMH and UB. PMH, Princess Marina Hospital; UB, University of Botswana; UPenn, University of Pennsylvania.
carefully considering the translation of science into practice based on cultural values, feasibility, resources and acceptance of authoritative sources of scientific evidence by Botswana health-care providers. Global literaturebased methodologies and resources and recommendations were drawn from international professional organizations and societies.
Navigating and leveraging networks and systems Botswana colleagues’ visit to the UPenn
One lead UPenn team member assumed responsibility for coordinating all learning experiences for a given week, arranging for transportation, collecting and distributing scientific materials and other resources, and providing primary mentorship to the visiting scholar team. Experiences included classroom learning in both academic and clinical settings, daily team debriefing sessions, cultural experiences and collaborative team work to design a © 2014 Wiley Publishing Asia Pty Ltd
translational science project ready for implementation when Botswana scholars returned to Gaborone. Kirkpatrick’s Model of Learning Evaluation served as the framework for navigating and leveraging networks and systems for specific learning activities and methods of evaluation for the USA site visit18 (see Table 2). While in the USA, Botswana team members were all given access to UPenn’s library resources and training in conducting literature searches by a UPenn librarian. Each Botswana scholar received an iPad purchased through grant funds to retrieve and store electronic resources. On the academic side, Botswana scholars attended classes on research, women’s health and global health. Uniquely, they observed the three UPenn Standing-CE Track faculty (authors MS, RCP, VLR) bridge academia and practice in their professional roles. Opportunities were provided to meet with several UPenn faculty members who had visited Botswana and/or were engaged in ongoing research in Botswana to exchange
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Table 2 Adaptation of Kirkpatrick’s levels of learning evaluation13 Level Evaluation type Evaluation description and (what is measured) characteristics UPenn Experience for Botswana scholars 1 Reaction Reaction evaluation is how the delegates felt about the training or learning experience. 2 Learning Learning evaluation is the measurement of the increase in knowledge—before and after. Botswana scholars’ work behaviors upon return to Botswana: putting learning into action 3 Behaviour Behaviour evaluation is the extent of applied learning back on the job— implementation.
4
Results
Results evaluation is the effect on the business or environment by the trainee.
Examples of evaluation tools/methods
Relevance and practicability
Daily and weekly debriefing sessions Daily critiques of learning experiences Reflective learning Journaling
Learning experiences and practices were consistently evaluated for feasibility within the Botswana education and health-care system.
Botswana clinical nurses and nurse leaders: • Participated in interdisciplinary team meetings/rounds • Implemented new patient care practices post-surgical patients • Developed new documentation tools and evaluation of nursing care outcomes • Utilized the Rapid Results Methodology to bring about change in patient care.
Newly learned leadership and clinical practices were adapted to conform to cultural norms. New practices were trialled and evaluated by clinical staff. Realistic timelines were established to implement new patient care practices.
Newly integrated practices in the Botswana nurse scholars led an interdisciplinary team in care of surgical patients were implementing an Enhanced expanded to other patient populations and units. Recovery Critical Pathway for 45 adult male surgical patients over a 5 month period.
powerful stories about changes in the Botswana healthcare system. For clinical care at HUP, Botswana scholars spent time with nurse leaders, clinical educators and advanced practice registered nurses. They experienced several nursing leadership and interprofessional meetings to observe effective collaboration and communication. All Botswana visiting scholars spent time on patient care units witnessing first hand how HUP clinical nurses formulate plans of care, make autonomous clinical decisions, and collaborate with physicians and other health-care professionals in team-based care. Prevention strategies and monitoring of nursing-sensitive outcomes, along with best practices, centered on hospital-acquired pressure ulcers (HAPUs),
central line-associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Botswana scholars met with HUP EBP Committee members to discuss how projects are initiated and EBP guidelines influence care. To experience how nurses are empowered to direct and affect change through interprofessional collaboration, Botswana scholars attended Unit-based Clinical Leadership (UBCL) meetings where physicians, nurses and other care team members in leadership roles collaborate to share accountability for unit- and patient population-specific performance improvement outcomes. Every Friday, the Botswana team dedicated time to reflect on the week’s experiences, and observed © 2014 Wiley Publishing Asia Pty Ltd
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leadership, clinical and educational practices that could realistically be translated into their health care and academic settings as well as those that would not be feasible at the time. The UPenn-Botswana team also worked on the design of critical care pathway to structure and guide nursing care on the most challenging unit at PMH—the Male Surgical Ward (MSW). The team agreed on the Rapid Results Methodology or Initiative (RRI) (originally conceived in Africa) as the framework for the project to improve care for general surgery patients. The RRI methodology uses the progressive implementation of quality initiatives to bring about meaningful change in 100 days.19 A draft was assembled for an ‘Enhanced Recovery Surgical Critical Pathway’ with the intent of improving patient outcomes such as pain, nutrition and activity, and reducing the length of hospitalization for patients on the MSW from 7 to 10 days to 3 to 5 days. The pathway incorporated EBP guidelines for pain care, patient monitoring and other aspects of post-surgical care. At the completion of the month-long immersion experience, structures and processes were planned for a successful programme implementation in Botswana.
Botswana scholars return to Gaborone
Upon their return to PMH and UB, the Botswana team informed key stakeholders about their experiences in the USA, and shared educational and practice resources with colleagues. They engaged nurses, physicians, pharmacists and other health professionals and support service members in work to refine the critical pathway appropriate for the general surgical male population. The UPennBotswana team continued to engage in frequent Skype calls to seek approval of the critical pathway protocol by the PMH Ethics Committee, UB Institutional Review Board and MOH.
UPenn team visit to Botswana
Approximately two and half months following the return of the Botswana team to Gaborone, the three-member UPenn team (authors MS, RCP and LH) arrived in Gaborone to begin their 2 week immersion experience. It was evident that the Botswana team had already strengthened their relationships with officials from the MOH, the UB faculty leaders from the School of Nursing and Medicine, and nursing and physician leaders from PMH. The UPenn team went into action presenting over 15 in-service and grand rounds programmes for nurses and physicians and teaching in the school of nursing, reaching over 300 clinicians, faculty and students in total. © 2014 Wiley Publishing Asia Pty Ltd
To support practice and the implementation of the research-based ‘Enhanced Recovery Surgical Critical Pathway’, the UPenn-Botswana team collaborated with anaesthetists, surgeons and clinical nurses to develop a comprehensive post-surgical pain protocol that capitalized on evidence-based multi-modal analgesic strategies for aggressive pain control20,21 and EBP patient monitoring practices22 with broad applicability to various surgical populations. Importantly, this protocol used the RADAR approach (Responsibility, Anticipation, Discussion, Assessment and Response) to promote interdisciplinary pain care and underscore that pain management should be on everyone’s radar.23 Approximately 75 international and USA EPB guidelines, research publications and review articles were compiled to support clinical decisionmaking in post-surgical care. An all-day workshop sponsored by the MOH for 37 area nursing leaders and educators was held to highlight the critical pathway project and to teach aspects of practice leadership for achieving excellence in clinical care. While In Botswana, the UPenn team visited various facilities such as health clinics, a health post and a remote mobile stop where Botswana nurses work to experience the transitions in levels of care.
Strengthening team dynamics The initial time invested in strategic global planning was successful in strengthening team dynamics over time. This strategy of methodical planning, team building, and use of frameworks and models to explicate the strategic work and its evaluation proved invaluable in achieving strategic goals. Now separated by over 7000 miles, the UPennBotswana team continues to communicate regularly by Skype to complete the Enhanced Recovery Surgical Critical Pathway Project and discuss new opportunities for advancing the scientific foundations for nursing education and practice.
DISCUSSION—ADDRESSING THE CHALLENGES The UPenn-Botswana Nursing Collaboration is an expansion of a strong existing partnership that has enabled student experiences, faculty research and collaborations among academic leaders. However, our collaboration involved a new team of emerging leaders in Botswana and UPenn nursing faculty, and this specific collaboration spanned practice, education and research training. Our challenges were not unique in initiating a productive
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partnership; however, our initial planning addressed one important challenge. To be successful in endeavours to change practice through the translation of new knowledge and EBP guidelines in developing countries, representatives from these countries need to experience practice environments that successfully accomplish these challenges, and have time to assimilate these experience. As such, the immersion experience at UPenn allowed our Botswana team to determine the feasibility of adopting changes in practice and prioritize those having the greatest impact on the health and well-being of their patient populations. Moreover, when USA representatives visit developing countries to influence change, they can be more prepared and focused if they, too, have an a priori understanding of the current health-care challenges. Others have emphasized the importance of identifying specific needs, developing strong and sustained partnerships, and addressing barriers by creating and trialling effective solutions to ongoing challenges.24 The National Institutes of Health team science field guide with a team science focus was extremely beneficial in streamlining our work. Other models served as the foundational frameworks for planning and organizing the course of action and defining measureable outcomes for an integrative approach embracing training in practice, education and research. Model-driven global partnerships incorporating team science must account for a universal understanding of the contextual interpretations, and this includes team science. Stokols et al.25 provide an excellent analysis of the contextual influences on transdisciplinary collaboration with team science, and we found this especially useful in our efforts to engage physicians and other health-care professionals at PMH and UB in the critical pathway research project for male surgical patients. Interestingly, they emphasized the importance of measuring the effects of every team science interdisciplinary encounter. As an example, during an interdisciplinary team meeting at PMH, the UPenn-Botswana team discussed the scientific basis for interventions to prevent surgical complications, especially the need for early mobilization. Patients on the PMH MSW often remained in bed sometimes way beyond 24 h following surgery. The next day, several chairs were delivered to the ward as a result of actions taken by one of the PMH surgeons. In response to another interdisciplinary encounter underscoring the need for pain reduction strategies with multimodal analgesia, a pharmacist took measures to increase the availability of specific analgesics.
Other challenges not often easily managed were issues related to resource allocation for implementing EBPs in a developing country. For example, the pain protocol for post-surgical patients had to be adjusted to include analgesic agents that were available and accessible. Opioid-based regimens for pain control on general care wards could not be maximized due to the lack of opioid medications. The UPenn team remained sensitive to these issues, and attempted to introduce EBP guidelines, research-based practices and clinical support tools that were universally accepted throughout the world and not just those unique to the USA. At times, language barriers presented a challenge as meanings were lost in translation. Distance communication was difficult, with disruptions in Internet connections and email. Compensated faculty and clinician efforts at UPenn, PMH and UB were especially problematic as this effort required the dedicated work of many individuals, including clinical nurses whose work demands were increased as a result of our project for surgical patients. Often, lead UB nursing faculty researchers and PMH leaders had to assume additional responsibilities in the clinical care. The success of implementing a new evidence-based care pathway for surgical patients at PMH and the engagement of an interdisciplinary care team made this experience a most rewarding one.
ACKNOWLEDGEMENTS This collaboration was partially supported by funding from the University of Pennsylvania (UPenn) Tiffany Foundation Grant and in-kind support from UPenn, UB, PMH and the Botswana Ministry of Health. The authors wish to express their gratitude to Afaf I. Meleis, PhD, DrPS(hon), FAAN, Margaret Bond Simon Dean of Nursing, UPenn School of Nursing, Motshedises Sabone, PhD, RN, Head of the UB School of Nursing, and Harvey Friedman, MD, Director of the Botswana-UPenn Partnership and Professor of Medicine, UPenn Perelman School of Medicine for their continued support for the UPenn-Botswana Nursing Collaborative. A special thanks to Geralyn Grosso for all her efforts in supporting the logistics of this global partnership.
REFERENCES 1 George EK, Meadows-Oliver M. Searching for collaboration in international nursing partnerships: A literature review. International Nursing Review 2013; 60: 31–36. 2 Harper DC, Davey KS, Fordham PN. Leadership lessons in global nursing and health from the nightingale letter © 2014 Wiley Publishing Asia Pty Ltd
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collection at the University of Alabama at Birmingham. Journal of Holistic Nursing 2014; 32: 44–53. Vermund SH, Sahasrabuddhe VV, Khedkar S, Jia Y, Etherington C, Vergara A. Building global health through a center-without-walls: The Vanderbilt Institute for Global Health. Academic Medicine 2008; 83: 154–164. Koplan JP, Baggett RL. The Emory Global Health Institute: Developing partnerships to improve health through research, training, and service. Academic Medicine 2008; 83: 128–133. Bosworth TL, Haloburdo EP, Hetrick C, Patchett K, Thompson MA, Welch M. International partnerships to promote quality care: Faculty groundwork, student projects, and outcomes. Journal of Continuing Education in Nursing 2006; 37: 32–38. Lasater K, Upvall M, Nielsen A, Prak M, Ptachcinski R. Global partnerships for professional development: A Cambodian exemplar. Journal of Professional Nursing 2012; 28: 62–68. Powell DL, Gilliss CL, Hewitt HH, Flint EP. Application of a partnership model for transformative and sustainable international development. Public Health Nursing 2010; 27: 54–70. Ersek M, Sebego M, Bloom AM, Shaibu S, McMenamin E, Mokotedi M. Development and evaluation of an international, interdisciplinary palliative care workshop in Botswana. International Journal of Palliative Nursing 2010; 16: 13–21. Central Intelligence Agency. The World Factbook. 2013. Available from URL: https://www.cia.gov/library/ publications/the-world-factbook/fields/2119.html. Accessed 1 March 2014. Sinha N, Onyyatsteng G. The nursing labour market in Botswana: An economic analysis. PULA: Botswana Journal of African Studies 2102; 26: 109–124. World Health Organization. World Health Statistics 2012. Geneva: World Health Organization, 2012. Mrayyan MT. Jordanian nurse’s job satisfaction, patients’ satisfaction and quality of nursing care. International Nursing Review 2006; 53: 224–230. Seboni NM. Chapter 2: Botwsana. In: Klopper HC, Uys LR (eds). The State of Nursing and Nursing Education in Africa: A Country-By-Country Review. Indianapolis, IN: Sigma Theta Tau International, 2013; 25–40.
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14 Bennett L, Gadlin H, Levine-Finley S. Collaboration and Team Science: A Field Guide. Bethesda: National Institutes of Health, 2010. 15 Covey S. The Seven Habits of Highly Effective People. New York: Free Press, 2004. 16 Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations Tools for Talking When Stakes are High, 2nd edn. New York: McGraw-Hill, 2011. 17 Donabedian A. Evaluating the quality of medical care. The Milbank Quarterly 2005; 83: 691–729. 18 Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels, 3rd edn. San Francisco, CA: Berrett Koehler Publishers Inc, 1994. 19 Sylvester O. Rapid Results Approach / Initiative: Institutionalization of Results Based Management in Kenya Public Service. Available from URL: http://www.capam.org/ _documents/rapidresultsapproach.kenya.pdf. Accessed 20 June 2013. 20 Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet 2006; 367: 1618– 1625. 21 Macintyre PE, Scott DA, Schug SA, Visser EJ, Walker SM (eds.). Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine: Acute Pain Management Scientific Evidence (3rd ed.). 2010. Available from URL: http://www.anzca.edu.au/resources/college-publications/ pdfs/Acute%20Pain%20Management/books-andpublications/acutepain.pdf. Accessed 10 August 2013. 22 Jarzyna D, Jungquist CR, Pasero C et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing 2011; 12: 118–145. 23 Vickers A, Bali S, Baxter A et al. Consensus statement on the anticipation and prevention of acute postoperative pain: Multidisciplinary RADAR approach. Current Medical Research and Opinion 2009; 25: 2557–2569. 24 Rybak N, Koster M, Gilbert EB, Flanigan T. Building international collaborations from the ground up: Brown university partnerships in Haiti and Ukraine. Rhode Island Medical Journal 2013; 96: 33–37. 25 Stokols D, Hall KL, Taylor BK, Moser RP. The science of team science: Overview of the field and introduction to the supplement. American Journal of Preventive Medicine 2008; 35 (2S): S77–S89.
