Strengthening healthcare delivery in Haiti through nursing continuing education M. Clark1 BSc, MSc(A), M. Julmisse2 RN, BScN, N. Marcelin3 RN, BN, L. Merry4 RN, MSc (A), PhD (c), J. Tuck5 RN, MSc (A) & A.J. Gagnon6,7 MPH, PhD
RN,
1 Graduate Student, 4 PhD(c), 5 Lecturer, Ingram School of Nursing, 6 Scientist, Research Institute, 7 Professor, McGill University Health Centre, McGill University, Montreal, Canada, 2 Chief Nursing Officer, Partners in Health, 3 Lead Nurse Educator, Zanmi Lasante, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
CLARK M., JULMISSE M., MARCELIN N., MERRY L., TUCK J. & GAGNON A.J. (2015) Strengthening healthcare delivery in Haiti through nursing continuing education. International Nursing Review 62, 54–63 Aim: The aim of this paper was to (1) highlight nursing continuing education as a key initiative for strengthening healthcare delivery in low-resource settings, and (2) provide an example of a nursing continuing education programme in Haiti. Background: Haiti and other low-resource settings face extreme challenges including severe shortages of healthcare workers, high rates of nurse out-migration and variations in nurse competency at entry-to-practice. Nursing continuing education has the potential to address these challenges and improve healthcare delivery through enhanced nurse performance and retention; however, it is underutilized in low-resource settings. Methods: A case study is presented from the Hôpital Universitaire de Mirebalais in Mirebalais, Haiti of a new nursing continuing education programme called the Beyond Expert Program. Results: The case study highlights eight key dimensions of nursing continuing education in low-resource settings: (1) involving local stakeholders in planning process, (2) targeting programme to nurse participant level and area of care, (3) basing course content on local context, (4) including diverse range of nursing topics, (5) using participatory teaching methods, (6) addressing resource constraints in time and scheduling, (7) evaluating and monitoring outcomes, and (8) establishing partnerships. The case study provides guidance for others wishing to develop programmes in similar settings. Conclusion: Creating a nursing continuing education programme in a low-resource setting is possible when there is commitment and engagement for nursing continuing education at all levels of the organization. Implications for Nursing and Health Policy: Our report suggests a need for policy-makers in resource-limited settings to make greater investments in nursing continuing education as a focus of human resources for health, as it is an important strategy for promoting nurse retention, building the knowledge and skill of the existing nursing workforce, and raising the image of nursing in low-resource settings.
Correspondence address: Dr Anita Gagnon, McGill University Health Centre, 2155 Rue Guy, #400-09, Montreal, Quebec H3H 2R9, Canada; Tel: (514)-934-1934 x 34713; Fax: (514)-843-1439; E-mail: [email protected].
Funding source The project received no operating funds from any agency in the public, commercial, or not-for-profit sectors. MC received personal support from the McBurney Fellowship Program, McGill University. Conflict of interest No conflict of interest has been declared by any of the authors.
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Keywords: Continuing Education, Curriculum Planning, Education, International Health, Nursing, Nursing Competence, Nursing continuing education
Introduction Across the globe, countries are facing health workforce challenges related to issues of both availability and performance, with identified 57 countries identified as being in the midst of a health workforce crisis. (WHO 2006). The success of a healthcare system is inextricably linked to the size, distribution, composition and skills of its healthcare workers. Discussions about health human resources, however, too often focus on the number of each kind of profession that is needed and neglect to engage in issues related to training and education, which play a central role in quality of care, and by extension the efficiency of healthcare delivery. The nursing profession has an important role in health systems, by increasing access to healthcare services and improving health outcomes in the populations it serves (WHO 2011). An estimated 35 million nurses and midwives comprise 60–80% of the global healthcare workforce and provide 90% of all healthcare services (Davis 2012, WHO 2010). In many lowresource settings, however, the nursing workforce remains understaffed, undertrained and poorly deployed. In order for nurses to be effective, they must be adequately educated and prepared to meet the needs of the patients they care for. Reports on the nursing workforce in low-resource regions such as Latin America and Sub-Saharan Africa, have identified continuing education as a critical area on the nursing development agenda and as an approach for strengthening the nursing profession (Malvárez & Castrillón 2005; Munjanja et al. 2005). The aims of this paper were to (1) highlight nursing continuing education as an important initiative for strengthening healthcare delivery and the nursing workforce in low-resource settings, and (2) provide an example of how nursing continuing education is currently being promoted within one healthcare organization in Haiti.
Nursing continuing education as an important initiative Nursing continuing education has been defined as ‘any postbasic nursing education aimed at actively engaging nurses in a lifelong process of learning, with the ultimate goal of improving healthcare delivery and patient outcomes’ (Griscti & Jacono 2006). There is a vast amount of literature on nursing continuing education in high-income countries. To identify
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literature on nursing continuing education in low-resource settings, we conducted a database search (CINAHL, Medline, PubMed) using various combinations of the keywords: ‘nurse’, ‘nursing’, ‘continuing education’, ‘professional development’, ‘low-resource’, ‘limited-resource’, ‘low-income’, and ‘developing countries’. Grey literature including reports from the World Health Organization (WHO) and International Council of Nurses was also searched. The search yielded little relevant literature, with only a few studies that were nursing-specific and that described or evaluated continuing education initiatives in low-resource settings (Nsemo et al. 2013; Thomas et al. 2000). A few papers examined continuing education for health workers generally, including nurses (Dieleman et al. 2009). The grey literature focused on the importance of continuing education as a health human resource initiative, however, it did not provide examples of programmes currently in place or being developed (Buchan & Calman 2004). Taken together, the small number of reports/papers focusing on low-resource settings and the extensive research in high-income countries suggest three potential and interrelated benefits of nursing continuing education in low-resource settings: (1) improved nurse retention and decreased outmigration, (2) increased job-related motivation, and (3) greater professional identity and unity. Many low-income countries are challenged with extremely high rates of nurse outmigration. Cited push factors for outmigration include a lack of professional recognition, limited professional development, and few opportunities for advancement or participation in leadership. It has been stated that ‘no matter how strong the pull factors are of recipient countries, migration only seems to result if there are also strong push factors from the donor country’ (Padarath et al. 2003). Continuing education is a means to address cited push factors, as it is a form of professional development, recognizes the important contribution of nurses, provides opportunities for professional development, and assists in developing leadership skills to facilitate nurse participation at management levels. In high-income settings, the link between continuing education and improved retention is questionable as studies have shown conflicting results regarding the relationship between opportunities for professional development and reduced turnover (Lehmann et al. 2008). In low-resource settings, however, evidence of a positive effect appears to be greater. For example,
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in a six-country study in Africa where skilled health personnel in the public sector of each country were interviewed, a strong relationship between retention of health personnel and continuing education was demonstrated (Awases et al. 2004). A cyclical pattern exists in many low-resource settings where nursing shortages and high turnover are associated with decreased staff morale among remaining nurses, which in turn is associated with an increased likelihood among these nurses to leave their nursing positions and in doing so, further augment shortages (Zurn et al. 2005). Understaffing and inadequate skills and knowledge to cope with the workload leads to nurses feeling over-stretched, inadequate in their role, undervalued and ultimately to them ‘giving-up’ and leaving the nursing profession. Job-related motivation is therefore a key determinant of health worker performance and length of stay in a position (Rowe et al. 2005). Continuing education has been suggested as a mechanism for improving retention rates by raising morale and job satisfaction (Malvárez & Castrillón 2005; Zurn et al. 2005). A study among rural health workers in North Vietnam, for example, revealed that training was identified as one of the most motivating factors in their job, along with appreciation by managers, colleagues, and the community, a stable job, and income (Dieleman et al. 2003). Increased motivation leads not only to improved care and patients’ needs being addressed, but also to a greater sense of pride and contentment with one’s work and ultimately commitment to their employers, patients and the profession. Lastly, continuing education programmes foster professional identity and unity, and raise the image of nursing. In many lowresource settings, healthcare systems remain patriarchal, and nurses lack a strong professional identity (Thomas et al. 2000). When a healthcare institution invests in nursing continuing education, it is acknowledging the invaluable contribution of nursing to healthcare and recognizing nurses as key players. This recognition and investment in the profession empowers nurses by creating a sense of self-worth and competence that comes from acquiring clinical expertise. Nurses who demonstrate high levels of professional commitment are more satisfied with their position, perceive that their work is worthwhile, and remain working in the nursing profession longer (Nsemo et al. 2013).
Methods A case study from Haiti is presented as an example of how nursing continuing education is presently being used to strengthen healthcare delivery in a low-resource setting. The case study provides important contextual background of the setting and the healthcare organization developing the programme, then a description of the programme itself.
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The Haitian context
Any health human resource initiative must be firmly founded on contextual knowledge and consider the effects of local social, political, geographic, economic and technological factors. One of the biggest challenges present in Haiti is an extreme shortage of healthcare personnel. The most recent estimates from the Haitian Ministry of Health (MSPP – Ministère de la Santé Publique et de la Population) report 6442 doctors, nurses and midwives working in Haiti as of 2013, providing care for a population of approximately 10 million (MSPP, 2014). These numbers correspond to 6.4 doctors, nurses and midwives per 10 000 population, a number well below the 23 deemed sufficient by the WHO. This shortage is further exacerbated by an unequal geographic distribution within the country, with the vast majority of healthcare professionals residing in urban areas. For example, of the 180 surgeons working in Haiti, 119 are located in the Département de l’Ouest, which encompasses only 35% of the population (Institut Haitien de Statistique et d’Informatique 2009, MSPP, 2014). Nursing shortages are linked to many factors including lack of investment in education and limited infrastructure, and they are exacerbated in many low-resource settings such as Haiti by high levels of nurse migration to industrialized settings (Buchan & Calman 2004). The exodus of educated individuals from lowincome countries is commonly termed brain drain, and has important effects on development. According to data from 2000, there were 13 001 Haitian born nurses working in foreign OECD countries, representing an expatriation rate of 94% (OECD 2007). Meaning that over 90% of nurses born in Haiti were not working in their country of origin. Other sources estimate that half of all new nursing graduates will leave Haiti within 5 years of graduation (Garfield & Berryman 2012). Shortages of healthcare personnel have important effects on the role and practice of those remaining, as it forces nurses to take on tasks that are not usually within their scope of practice. Prescribing medication, making diagnoses and determining interventions are among tasks shifted to nurses, often without any supplemental education (Malvárez & Castrillón 2005). Many rural healthcare facilities in Haiti are staffed exclusively by nurses and have only intermittent physician support. Furthermore, the shortage of registered nurses in Haiti frequently results in hospitals filling nursing positions with lesser-trained nursing auxiliaries. In many low-income countries, nurse auxiliaries are responsible for nearly all direct-care delivery and comprise up to 80% of the nursing workforce (Malvárez & Castrillón 2005). Thirty-five nursing schools are recognized by the Haitian Ministry of Health, including four state schools. Prior to 2014, there was no standardized curriculum or established norms and
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standards for nursing practice, which resulted in variations in nursing education across and between public and private institutions. The cumulative effect of these challenges in Haiti is a nursing workforce that is insufficient in number, has great variability in training and competency level, is operating in an expanded role, and as a result, is inadequately equipped to meet the healthcare needs of the populations they serve. An important long-term response to this challenge is to build capacity within nursing schools and increase the number of nursing students (International Council of Nurses 2006). However concurrent initiatives also need to be put in place, which address the problem in the short-term by promoting nurse retention and building the skills of the already existing nursing workforce. Support for nursing continuing education has been voiced by the Haitian MSPP in a 2014 report that recognizes the need for more training opportunities in nursing specializations and identifies human resources for health as a top priority (MSPP, 2014). The MSPP commitment to nursing is seen in recent activities, such as validating national Norms and Standards in the Practice of Nursing, finalizing a new curriculum for the National Schools of Nursing, and beginning the legislative process of creating a National Order of Nurses. Nursing continuing education programmes are in line with the goals of the ministry and are currently being implemented by the healthcare organization Zanmi Lasante (ZL). ZL and Hôpital Universitaire de Mirebalais (HUM)
ZL/Partners in Health (PIH) are the largest nongovernment healthcare providers in Haiti, working alongside the MSPP to serve an area of 1.3 million people at 12 sites across Haiti’s Central Plateau and lower Artibonite regions. Nursing staff make up 85.5% of all clinical staff, and ZL believes in working with partner organizations and the national Ministry of Health to strengthen nursing efforts and raise nursing visibility (Davis 2012). In the structural organization of the HUM, ZL’s newest tertiary care hospital, the Chief Nursing Officer is on the same level as the Chief Medical Officer. This is evidence of the commitment of ZL to nursing and their recognition of nurses as key players in decision making (PIH, 2014). HUM is scheduled to provide new advanced care services in the near future (e.g., intensive care unit), which requires that their nurses quickly acquire specialized knowledge and skills to meet the complex needs of high-acuity patients in critical-care units (Stefanski & Rossler 2009). Yet at the present time, no formal opportunity for specialized critical-care training exists in Haiti. A comprehensive continuing education programme was therefore developed to: (1) address the new learning needs inherent in the advanced care to be provided at HUM, (2)
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address gaps in education across clinical areas, (3) ensure all ZL nurses have a uniform knowledge base, and (4) serve as a foundation for ongoing professional development activities. The Beyond Expert Program
The continuing education programme is termed ‘The Beyond Expert Program’ (BEP) and was developed to address the unique nursing situation of Haiti and meet the critical-care needs of HUM. The aim of the BEP was to guide nurses through the transition from novice practitioners to proficient nursing professionals. The concept originated from Benner’s theory, an adaptation of the Dreyfus Model of Skill Acquisition, which purports that nurses transition along a five-stage continuum from novice to expert throughout their career, and can advance to higher levels of performance through both experiential and situated learning (Benner 1982).
Results The following eight components are recommended in the literature as important to the success of continuing education programmes. For each dimension, we demonstrate and provide examples of how the recommendation was incorporated in the BEP. Involving stakeholders in the planning process
According to literature from low-resource settings, the success and sustainability of continuing education policies and programmes can be greatly enhanced by including all stakeholders in discussions prior to implementation (Dieleman et al. 2009; Griscti & Jacono 2006). Involvement of local staff to identify and implement solutions to problems is critical to successful implementation and can lead to longer-lasting effects (Dieleman et al. 2009). With this in mind, input during the planning process for the BEP was sought from various players including the Director of Nursing of the MSPP, ZL leadership staff, and HUM head nurses. The Chief Nursing Officer at HUM is spearheading the project and will continue to seek stakeholder involvement. Targeting programme to nurse participant level and area of care
Evidence suggests that continuing education is most effective and well-received when it is tailored to both the level and area of care of participating nurses (Dieleman et al. 2009; Nsemo et al. 2013). This was the rationale for organizing the BEP into different modules specific to the area of care of nurse participants. Figure 1 depicts the eight modules of the BEP, which correspond to the hospital units at HUM as shown in blue. The final ‘Beyond Expert’ module is intended for nurses from all care areas and focuses specifically on nursing leadership and
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Fig. 1 Diagram of modules in the Beyond Expert Program. Legend: purple, programme module; blue, corresponding hospital unit. ICU, intensive care unit; NICU, Neonatal Intensive Care Unit; PACU, Post-Anaesthesia Care Unit; PICU, Paediatric Intensive Care Unit.
research. Each module is divided into four blocks that correspond to first four stages of Benner’s theory: Novice – block 1; Adv. Beginner – block 2; Competent – block 3; and Proficient – block 4. The programme is tailored to the level of the nurse through this progressive learning structure, where material builds on what was previously covered and goes into more advanced content as the learner progresses along the continuum. Table 1 is an example taken from the Adult Critical Care Module, which shows how course content progresses from foundation material in block 1 to increasingly complex subjects. For example, in block 1, respiratory assessment is covered before resuscitation and intubation are subsequently introduced in blocks 2 and 4. Table 2 goes into greater depth and is an example of the curriculum outline that will be completed for each subject. Basing course content on local context
It is essential that content be based on local problems, relevant to the local context, and take into account available resources and diagnostic tools (Dieleman et al. 2009; Nsemo et al. 2013). To ensure relevancy of course content, the BEP is being developed by the HUM/ZL nursing team, all of whom are familiar with the context and are responsible for ensuring relevancy of course content. For each specific module, the nurse manager of the corresponding hospital unit will be actively involved in curriculum development. The managers are knowledgeable about
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available resources, common practices on the units and nursing issues faced by members of their team. As much as is possible, local professors will be recruited to teach modules, further ensuring relevancy to context. Including diverse range of nursing topics
The literature cautions against content that is too heavily focused on the technical aspects of nursing practice and fails to address other aspects of nursing such as critical thinking, interpersonal skills and leadership (Nsemo et al. 2013). Course content will therefore include aspects of nursing such as conflict resolution, communication and the nursing process, as well as technical components such as medication administration. The most frequent issues observed with novice nurses as identified in the literature will also be incorporated into the programme. For example, lack of knowledge about appropriate delegation, inability to interpret lab data, and poor prioritization and time management skills (Stefanski & Rossler 2009). Using participatory teaching methods
Appropriate and effective teaching strategies are essential to ensure translation of knowledge into practice (Anderson et al. 2012). In a report of nurse perceptions of continuing education programmes in Nigeria, nurse respondents desired continuing education programmes that were learner-driven and flexible, with technology-based methods used to enhance self-directed
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Pre-/post-tests Course evaluations Written exam Self-evaluation
Evaluation methods
Teaching Methods:
Assessments Respiratory Cardiac Skin/integument Interventions Oxygen therapy Pain management Blood administration Preventative Hand washing Isolation precautions Professionalism Ethics Communication Didactic lectures (70%) Case studies (10%) Group discussion (10%) Self-directed learning (10%)
Specific courses and teaching topics:
Novice – block 1
Table 1 Example of Adult Critical Care Module
Post-test Course evaluations Competency evaluation Written exam Self-evaluation
Didactic lectures (40%) Clinical simulations (40%) Self-directed learning (20%)
Critical care II Arrhythmia Congestive heart Failure Renal failure Ischaemic and Haemorrhagic stroke Thrombosis Mentoring
Critical care I Lab value Interpretation Resuscitation (Basic Life Support) Shock ECG (Electrocardiogram) interpretation Wound care Burns
Didactic lectures (50%) Case studies (10%) Group discussion (10%) Clinical simulations (20%) Self-Directed Learning (10%) Pre-/post-tests Course evaluations Competency evaluation Written exam Self-evaluation
Competent – block 3
Adv. Beginner – block 2
Post-test Course evaluations Competency evaluation Written exam Self-evaluation
Didactic lectures (40%) Clinical Simulations (40%) Self-directed learning (20%)
Critical care III Central lines Arterial lines Care of patient on ventilator Intubation – meds, rapid sequence Weaning and extubation Multisystem trauma
Proficient – block 4
Ongoing continuing education
Expert
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Table 2 Example of curriculum outline for blood administration Objectives
Content outline
Learning resources
Clinical competencies
Demonstrates the correct sequence and documentation of the steps in the blood component administration policy/procedure Pre-transfusion Transfusion Identifies five signs and symptoms of a transfusion reaction Identifies five blood components and lists one indication for each Identifies equipment needed to set up and administer blood components
Background/rationale – transfusion safety Preparation of patient/equipment Order/consent Collection of type and screen sample Requesting blood component procedure Checking blood component for any discrepancies Administering blood components: Blood donor type and compatibility Solutions and tubing Infusion rates, first-five minutes, subsequent Time out of refrigeration Documentation: Response Intake/output Equipment discard Protocol for patient needing to leave unit signs/symptoms, onset and types of reactions Steps to be taken in event of suspected transfusion reaction Nurses role in managing and reporting a suspected transfusion reaction Review of blood components: red blood cells, fresh frozen plasma, cryoprecipitate, platelets and albumin and indications for each
PowerPoint presentation Case study Guidelines for Transfusion reaction Policies and procedures on blood component administration Transfusion reaction protocol Competency evaluation Checklist
Appropriately prepare patient and environment for care of patient receiving blood components Routine care Emergent care Verbalize how to correctly perform a type and screen as per facility’s procedure Utilize correct procedures during blood component check Understand rationale for administering specific blood components to patients Verbalize appropriate solutions compatible with blood components Verbalize two timeframes nursing is responsible for when administering blood components Verbalize at least five signs and symptoms of a transfusion reaction and appropriate nursing interventions Complete the facility’s transfusion reaction form. Follow appropriate steps in reporting a suspected transfusion reaction Verbalize indications for five different blood components
Associated simulation: blood product administration.
learning (Nsemo et al. 2013). Other suggestions from the literature that have been incorporated into the BEP include, limiting the amount of didactic content in favour of participatory sessions (Rowe et al. 2005), practising tasks in the field under supervision during training or as a follow-up (Dieleman et al. 2009; Lehmann et al. 2008), using a cascade training approach (Dieleman et al. 2009), and intra-professional socialization through discussion sessions aimed at sharing strategies about how to manage workplace stress (Anderson et al. 2012). Clinical simulations are a well-documented method that provide an opportunity to assess a nurse’s ability to apply concepts to clinical situations, adapt to emerging priorities, and recognize emergency situations (Stefanski & Rossler 2009).
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Addressing resource constraints in time and scheduling
Two of the identified barriers to continuing education are time/ scheduling constraints and insufficient notice of presentations (Griscti & Jacono 2006; Nsemo et al. 2013). In the BEP, cohorts of 6–12 nurses will be created with each cohort participating in the module specific to their unit (e.g., emergency department nurses will attend the Adult Critical Care Module). Learning in groups is an excellent way to create safe, trusting, and collaborative learning environments, and promotes knowledge retention and teamwork when nurses return to their unit (Anderson et al. 2012). Each cohort will have a specific teaching day, which will be incorporated into their schedule by the nurse managers of each unit. Each block will consist of 56–72 h of instructional
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time distributed over 7–9 weeks in 8-h increments of continuing education days. Evaluating and monitoring outcomes
Evaluation and monitoring are crucial aspects of any continuing education programme. There is a noted gap in the literature regarding monitoring and long-term evaluation of continuing education programmes, which makes it difficult to objectively assess whether they result in successful outcomes (Dieleman et al. 2009). Evaluation is an essential part of the continuing education programme at HUM and includes a combination of methods. Structured observation and pre-/post-tests will assess retained knowledge of teaching sessions, whereas selfevaluations will assess more abstract areas such as perceived autonomy, job satisfaction and intent to stay (Anderson et al. 2012). The programme will also be evaluated both by participants and by an external third party. Effects on nurse retention will be assessed through self-reported intent to stay and turnover rates (i.e., length of time an employee remains in a position). Establish partnerships
Utilizing partnerships with local nursing schools, other healthcare institutions and international organizations helps increase the feasibility of implementing a continuing education programme in a low-resource setting. ZL has many existing partnerships and is adapting resources from these partners for use in the BEP. For example, HUM is currently in possession of a neonatal intensive care training curriculum that will be evaluated and modified for use in the Neonatal Critical Care Module. Early discussions with another hospital in Port-au-Prince have also introduced the possibility of acquiring a Paediatric Intensive Care training course that has already been developed by that institution. Partnerships with local nursing schools are of vital importance and will be utilized for recruitment of professors to teach modules.
Discussion Nursing continuing education is an underdeveloped and underutilized means to strengthen healthcare delivery in lowresource settings. The example from Haiti offered in our case study provides guidance for those wishing to develop similar programmes in Haiti, and low-resource settings in other countries. Our literature search found no other descriptions of comprehensive nursing continuing education programmes in a lowresource setting, so we are unable to compare our programme. Although many programmes have been described in highincome countries, the only documented nursing continuing
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education initiatives found in the literature for low-resource settings were focused on specific interventions, such as intramuscular injection (Walters & Furyk 2010). One of the main factors identified as crucial to facilitating development of the BEP was the commitment and support for nursing continuing education at both a national and institutional level. The MSPP clearly identifies continuing education for nurses as a key component of their healthcare strategy, and this commitment has been evidenced by involvement of the National Director of Nursing in meetings about the BEP. Commitment at the institutional level of HUM is reflected in the organizational structure of the hospital, which has empowered the Chief Nursing Officer and made it possible for her to allocate the necessary resources to move the project forward. Nursing is often not recognized in a management structure and lacks decision-making authority. Adequate recognition of the vital role of nursing in the health system and support for nursing continuing education at a national, organizational and institutional level is an important preceding factor for the successful development of programmes. Many health human resource initiatives carried out with the goal of improving healthcare delivery include monetary incentives such as increased wages, pensions and tuition reimbursement. In low-resource settings, financial resources are extremely limited, which constrains the use of monetary incentives and makes other less costly initiatives such as continuing education programmes more appealing. Although continuing education programmes do have inherent costs, many of the cost-intensive aspects such as curriculum development, lie in the planning phase and would only be necessary once. Potential effects of continuing education programmes on improved retention have cost-saving benefits, as high turnover is associated with high costs in training new employees. One of the limitations of this project at the present time is that programme implementation is incomplete and the first cohort of nurses has yet to complete the programme. However, the programme described can still serve as a starting point for other healthcare institutions in low-resource settings that wish to develop their own continuing education programmes.
Conclusion In the context of a global call to action on human resources for health, nursing continuing education is an important strategy for promoting nurse retention and professionalism, fostering motivation, and building the knowledge and skill of the existing nursing workforce in low-resource settings. Given that 90% of all global healthcare services are provided by nurses and midwives, strengthening care provided by this group will, by
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extension, strengthen healthcare systems as a whole by improving delivery of care, and resulting in sustained positive health outcomes for patients.
Implications for nursing and health policy Our review of existing reports suggests the need for policymakers in resource-limited settings to make greater investments in nursing continuing education as a focus of human resources for health. Despite increased recognition that health workers are critical to achieving health-related goals and fostering effective health systems, there is an inadequate amount of investment in health workers and in evaluation of education programmes directed towards them (Chopra et al. 2008). A range of research is needed to identify: (1) factors that contribute to a successful nursing continuing education programme, (2) best practices for programme development and implementation, and (3) effects of programmes on nurse retention, motivation, professionalism, and performance.
Acknowledgements We acknowledge the assistance of the nursing staff at Zanmi Lasante/Hôpital Universitaire Mirebalais, who provided information for the case study.
Author contributions MC, did data collection/analysis, and drafting of paper. MJ, did study conception and field supervision. NM, did critical revisions for important intellectual content and field supervision. LM, did drafting of paper and critical revisions for important intellectual content. JT, did supervision and critical revisions for important intellectual content. AJG, did study design, critical revisions for important intellectual content and supervision.
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Health: Nursing and Midwifery Office, ed.). World Health Organization, Geneva. World Health Organization (WHO) (2011) WHA 64.7 strengthening nursing and midwifery. In Sixty fourth World Health Assembly. World Health Organization, Geneva, pp. 1–4. Retrieved from: http:// apps.who.int/gb/ebwha/pdf_files/WHA64/A64_R7-en.pdf (accessed 13 January 2014). Zurn, P., Dolea, C. & Stilwell, B. (2005) Nurse retention and recruitment: developing a motivated workforce. In The Global Nursing Review Initiative, (I. C. O. Nurses, ed.). World Health Organization, Geneva, pp. 1–31.
RN,
1 Graduate Student, 4 PhD(c), 5 Lecturer, Ingram School of Nursing, 6 Scientist, Research Institute, 7 Professor, McGill University Health Centre, McGill University, Montreal, Canada, 2 Chief Nursing Officer, Partners in Health, 3 Lead Nurse Educator, Zanmi Lasante, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
CLARK M., JULMISSE M., MARCELIN N., MERRY L., TUCK J. & GAGNON A.J. (2015) Strengthening healthcare delivery in Haiti through nursing continuing education. International Nursing Review 62, 54–63 Aim: The aim of this paper was to (1) highlight nursing continuing education as a key initiative for strengthening healthcare delivery in low-resource settings, and (2) provide an example of a nursing continuing education programme in Haiti. Background: Haiti and other low-resource settings face extreme challenges including severe shortages of healthcare workers, high rates of nurse out-migration and variations in nurse competency at entry-to-practice. Nursing continuing education has the potential to address these challenges and improve healthcare delivery through enhanced nurse performance and retention; however, it is underutilized in low-resource settings. Methods: A case study is presented from the Hôpital Universitaire de Mirebalais in Mirebalais, Haiti of a new nursing continuing education programme called the Beyond Expert Program. Results: The case study highlights eight key dimensions of nursing continuing education in low-resource settings: (1) involving local stakeholders in planning process, (2) targeting programme to nurse participant level and area of care, (3) basing course content on local context, (4) including diverse range of nursing topics, (5) using participatory teaching methods, (6) addressing resource constraints in time and scheduling, (7) evaluating and monitoring outcomes, and (8) establishing partnerships. The case study provides guidance for others wishing to develop programmes in similar settings. Conclusion: Creating a nursing continuing education programme in a low-resource setting is possible when there is commitment and engagement for nursing continuing education at all levels of the organization. Implications for Nursing and Health Policy: Our report suggests a need for policy-makers in resource-limited settings to make greater investments in nursing continuing education as a focus of human resources for health, as it is an important strategy for promoting nurse retention, building the knowledge and skill of the existing nursing workforce, and raising the image of nursing in low-resource settings.
Correspondence address: Dr Anita Gagnon, McGill University Health Centre, 2155 Rue Guy, #400-09, Montreal, Quebec H3H 2R9, Canada; Tel: (514)-934-1934 x 34713; Fax: (514)-843-1439; E-mail: [email protected].
Funding source The project received no operating funds from any agency in the public, commercial, or not-for-profit sectors. MC received personal support from the McBurney Fellowship Program, McGill University. Conflict of interest No conflict of interest has been declared by any of the authors.
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Nursing Education
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Keywords: Continuing Education, Curriculum Planning, Education, International Health, Nursing, Nursing Competence, Nursing continuing education
Introduction Across the globe, countries are facing health workforce challenges related to issues of both availability and performance, with identified 57 countries identified as being in the midst of a health workforce crisis. (WHO 2006). The success of a healthcare system is inextricably linked to the size, distribution, composition and skills of its healthcare workers. Discussions about health human resources, however, too often focus on the number of each kind of profession that is needed and neglect to engage in issues related to training and education, which play a central role in quality of care, and by extension the efficiency of healthcare delivery. The nursing profession has an important role in health systems, by increasing access to healthcare services and improving health outcomes in the populations it serves (WHO 2011). An estimated 35 million nurses and midwives comprise 60–80% of the global healthcare workforce and provide 90% of all healthcare services (Davis 2012, WHO 2010). In many lowresource settings, however, the nursing workforce remains understaffed, undertrained and poorly deployed. In order for nurses to be effective, they must be adequately educated and prepared to meet the needs of the patients they care for. Reports on the nursing workforce in low-resource regions such as Latin America and Sub-Saharan Africa, have identified continuing education as a critical area on the nursing development agenda and as an approach for strengthening the nursing profession (Malvárez & Castrillón 2005; Munjanja et al. 2005). The aims of this paper were to (1) highlight nursing continuing education as an important initiative for strengthening healthcare delivery and the nursing workforce in low-resource settings, and (2) provide an example of how nursing continuing education is currently being promoted within one healthcare organization in Haiti.
Nursing continuing education as an important initiative Nursing continuing education has been defined as ‘any postbasic nursing education aimed at actively engaging nurses in a lifelong process of learning, with the ultimate goal of improving healthcare delivery and patient outcomes’ (Griscti & Jacono 2006). There is a vast amount of literature on nursing continuing education in high-income countries. To identify
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literature on nursing continuing education in low-resource settings, we conducted a database search (CINAHL, Medline, PubMed) using various combinations of the keywords: ‘nurse’, ‘nursing’, ‘continuing education’, ‘professional development’, ‘low-resource’, ‘limited-resource’, ‘low-income’, and ‘developing countries’. Grey literature including reports from the World Health Organization (WHO) and International Council of Nurses was also searched. The search yielded little relevant literature, with only a few studies that were nursing-specific and that described or evaluated continuing education initiatives in low-resource settings (Nsemo et al. 2013; Thomas et al. 2000). A few papers examined continuing education for health workers generally, including nurses (Dieleman et al. 2009). The grey literature focused on the importance of continuing education as a health human resource initiative, however, it did not provide examples of programmes currently in place or being developed (Buchan & Calman 2004). Taken together, the small number of reports/papers focusing on low-resource settings and the extensive research in high-income countries suggest three potential and interrelated benefits of nursing continuing education in low-resource settings: (1) improved nurse retention and decreased outmigration, (2) increased job-related motivation, and (3) greater professional identity and unity. Many low-income countries are challenged with extremely high rates of nurse outmigration. Cited push factors for outmigration include a lack of professional recognition, limited professional development, and few opportunities for advancement or participation in leadership. It has been stated that ‘no matter how strong the pull factors are of recipient countries, migration only seems to result if there are also strong push factors from the donor country’ (Padarath et al. 2003). Continuing education is a means to address cited push factors, as it is a form of professional development, recognizes the important contribution of nurses, provides opportunities for professional development, and assists in developing leadership skills to facilitate nurse participation at management levels. In high-income settings, the link between continuing education and improved retention is questionable as studies have shown conflicting results regarding the relationship between opportunities for professional development and reduced turnover (Lehmann et al. 2008). In low-resource settings, however, evidence of a positive effect appears to be greater. For example,
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in a six-country study in Africa where skilled health personnel in the public sector of each country were interviewed, a strong relationship between retention of health personnel and continuing education was demonstrated (Awases et al. 2004). A cyclical pattern exists in many low-resource settings where nursing shortages and high turnover are associated with decreased staff morale among remaining nurses, which in turn is associated with an increased likelihood among these nurses to leave their nursing positions and in doing so, further augment shortages (Zurn et al. 2005). Understaffing and inadequate skills and knowledge to cope with the workload leads to nurses feeling over-stretched, inadequate in their role, undervalued and ultimately to them ‘giving-up’ and leaving the nursing profession. Job-related motivation is therefore a key determinant of health worker performance and length of stay in a position (Rowe et al. 2005). Continuing education has been suggested as a mechanism for improving retention rates by raising morale and job satisfaction (Malvárez & Castrillón 2005; Zurn et al. 2005). A study among rural health workers in North Vietnam, for example, revealed that training was identified as one of the most motivating factors in their job, along with appreciation by managers, colleagues, and the community, a stable job, and income (Dieleman et al. 2003). Increased motivation leads not only to improved care and patients’ needs being addressed, but also to a greater sense of pride and contentment with one’s work and ultimately commitment to their employers, patients and the profession. Lastly, continuing education programmes foster professional identity and unity, and raise the image of nursing. In many lowresource settings, healthcare systems remain patriarchal, and nurses lack a strong professional identity (Thomas et al. 2000). When a healthcare institution invests in nursing continuing education, it is acknowledging the invaluable contribution of nursing to healthcare and recognizing nurses as key players. This recognition and investment in the profession empowers nurses by creating a sense of self-worth and competence that comes from acquiring clinical expertise. Nurses who demonstrate high levels of professional commitment are more satisfied with their position, perceive that their work is worthwhile, and remain working in the nursing profession longer (Nsemo et al. 2013).
Methods A case study from Haiti is presented as an example of how nursing continuing education is presently being used to strengthen healthcare delivery in a low-resource setting. The case study provides important contextual background of the setting and the healthcare organization developing the programme, then a description of the programme itself.
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The Haitian context
Any health human resource initiative must be firmly founded on contextual knowledge and consider the effects of local social, political, geographic, economic and technological factors. One of the biggest challenges present in Haiti is an extreme shortage of healthcare personnel. The most recent estimates from the Haitian Ministry of Health (MSPP – Ministère de la Santé Publique et de la Population) report 6442 doctors, nurses and midwives working in Haiti as of 2013, providing care for a population of approximately 10 million (MSPP, 2014). These numbers correspond to 6.4 doctors, nurses and midwives per 10 000 population, a number well below the 23 deemed sufficient by the WHO. This shortage is further exacerbated by an unequal geographic distribution within the country, with the vast majority of healthcare professionals residing in urban areas. For example, of the 180 surgeons working in Haiti, 119 are located in the Département de l’Ouest, which encompasses only 35% of the population (Institut Haitien de Statistique et d’Informatique 2009, MSPP, 2014). Nursing shortages are linked to many factors including lack of investment in education and limited infrastructure, and they are exacerbated in many low-resource settings such as Haiti by high levels of nurse migration to industrialized settings (Buchan & Calman 2004). The exodus of educated individuals from lowincome countries is commonly termed brain drain, and has important effects on development. According to data from 2000, there were 13 001 Haitian born nurses working in foreign OECD countries, representing an expatriation rate of 94% (OECD 2007). Meaning that over 90% of nurses born in Haiti were not working in their country of origin. Other sources estimate that half of all new nursing graduates will leave Haiti within 5 years of graduation (Garfield & Berryman 2012). Shortages of healthcare personnel have important effects on the role and practice of those remaining, as it forces nurses to take on tasks that are not usually within their scope of practice. Prescribing medication, making diagnoses and determining interventions are among tasks shifted to nurses, often without any supplemental education (Malvárez & Castrillón 2005). Many rural healthcare facilities in Haiti are staffed exclusively by nurses and have only intermittent physician support. Furthermore, the shortage of registered nurses in Haiti frequently results in hospitals filling nursing positions with lesser-trained nursing auxiliaries. In many low-income countries, nurse auxiliaries are responsible for nearly all direct-care delivery and comprise up to 80% of the nursing workforce (Malvárez & Castrillón 2005). Thirty-five nursing schools are recognized by the Haitian Ministry of Health, including four state schools. Prior to 2014, there was no standardized curriculum or established norms and
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standards for nursing practice, which resulted in variations in nursing education across and between public and private institutions. The cumulative effect of these challenges in Haiti is a nursing workforce that is insufficient in number, has great variability in training and competency level, is operating in an expanded role, and as a result, is inadequately equipped to meet the healthcare needs of the populations they serve. An important long-term response to this challenge is to build capacity within nursing schools and increase the number of nursing students (International Council of Nurses 2006). However concurrent initiatives also need to be put in place, which address the problem in the short-term by promoting nurse retention and building the skills of the already existing nursing workforce. Support for nursing continuing education has been voiced by the Haitian MSPP in a 2014 report that recognizes the need for more training opportunities in nursing specializations and identifies human resources for health as a top priority (MSPP, 2014). The MSPP commitment to nursing is seen in recent activities, such as validating national Norms and Standards in the Practice of Nursing, finalizing a new curriculum for the National Schools of Nursing, and beginning the legislative process of creating a National Order of Nurses. Nursing continuing education programmes are in line with the goals of the ministry and are currently being implemented by the healthcare organization Zanmi Lasante (ZL). ZL and Hôpital Universitaire de Mirebalais (HUM)
ZL/Partners in Health (PIH) are the largest nongovernment healthcare providers in Haiti, working alongside the MSPP to serve an area of 1.3 million people at 12 sites across Haiti’s Central Plateau and lower Artibonite regions. Nursing staff make up 85.5% of all clinical staff, and ZL believes in working with partner organizations and the national Ministry of Health to strengthen nursing efforts and raise nursing visibility (Davis 2012). In the structural organization of the HUM, ZL’s newest tertiary care hospital, the Chief Nursing Officer is on the same level as the Chief Medical Officer. This is evidence of the commitment of ZL to nursing and their recognition of nurses as key players in decision making (PIH, 2014). HUM is scheduled to provide new advanced care services in the near future (e.g., intensive care unit), which requires that their nurses quickly acquire specialized knowledge and skills to meet the complex needs of high-acuity patients in critical-care units (Stefanski & Rossler 2009). Yet at the present time, no formal opportunity for specialized critical-care training exists in Haiti. A comprehensive continuing education programme was therefore developed to: (1) address the new learning needs inherent in the advanced care to be provided at HUM, (2)
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address gaps in education across clinical areas, (3) ensure all ZL nurses have a uniform knowledge base, and (4) serve as a foundation for ongoing professional development activities. The Beyond Expert Program
The continuing education programme is termed ‘The Beyond Expert Program’ (BEP) and was developed to address the unique nursing situation of Haiti and meet the critical-care needs of HUM. The aim of the BEP was to guide nurses through the transition from novice practitioners to proficient nursing professionals. The concept originated from Benner’s theory, an adaptation of the Dreyfus Model of Skill Acquisition, which purports that nurses transition along a five-stage continuum from novice to expert throughout their career, and can advance to higher levels of performance through both experiential and situated learning (Benner 1982).
Results The following eight components are recommended in the literature as important to the success of continuing education programmes. For each dimension, we demonstrate and provide examples of how the recommendation was incorporated in the BEP. Involving stakeholders in the planning process
According to literature from low-resource settings, the success and sustainability of continuing education policies and programmes can be greatly enhanced by including all stakeholders in discussions prior to implementation (Dieleman et al. 2009; Griscti & Jacono 2006). Involvement of local staff to identify and implement solutions to problems is critical to successful implementation and can lead to longer-lasting effects (Dieleman et al. 2009). With this in mind, input during the planning process for the BEP was sought from various players including the Director of Nursing of the MSPP, ZL leadership staff, and HUM head nurses. The Chief Nursing Officer at HUM is spearheading the project and will continue to seek stakeholder involvement. Targeting programme to nurse participant level and area of care
Evidence suggests that continuing education is most effective and well-received when it is tailored to both the level and area of care of participating nurses (Dieleman et al. 2009; Nsemo et al. 2013). This was the rationale for organizing the BEP into different modules specific to the area of care of nurse participants. Figure 1 depicts the eight modules of the BEP, which correspond to the hospital units at HUM as shown in blue. The final ‘Beyond Expert’ module is intended for nurses from all care areas and focuses specifically on nursing leadership and
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Fig. 1 Diagram of modules in the Beyond Expert Program. Legend: purple, programme module; blue, corresponding hospital unit. ICU, intensive care unit; NICU, Neonatal Intensive Care Unit; PACU, Post-Anaesthesia Care Unit; PICU, Paediatric Intensive Care Unit.
research. Each module is divided into four blocks that correspond to first four stages of Benner’s theory: Novice – block 1; Adv. Beginner – block 2; Competent – block 3; and Proficient – block 4. The programme is tailored to the level of the nurse through this progressive learning structure, where material builds on what was previously covered and goes into more advanced content as the learner progresses along the continuum. Table 1 is an example taken from the Adult Critical Care Module, which shows how course content progresses from foundation material in block 1 to increasingly complex subjects. For example, in block 1, respiratory assessment is covered before resuscitation and intubation are subsequently introduced in blocks 2 and 4. Table 2 goes into greater depth and is an example of the curriculum outline that will be completed for each subject. Basing course content on local context
It is essential that content be based on local problems, relevant to the local context, and take into account available resources and diagnostic tools (Dieleman et al. 2009; Nsemo et al. 2013). To ensure relevancy of course content, the BEP is being developed by the HUM/ZL nursing team, all of whom are familiar with the context and are responsible for ensuring relevancy of course content. For each specific module, the nurse manager of the corresponding hospital unit will be actively involved in curriculum development. The managers are knowledgeable about
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available resources, common practices on the units and nursing issues faced by members of their team. As much as is possible, local professors will be recruited to teach modules, further ensuring relevancy to context. Including diverse range of nursing topics
The literature cautions against content that is too heavily focused on the technical aspects of nursing practice and fails to address other aspects of nursing such as critical thinking, interpersonal skills and leadership (Nsemo et al. 2013). Course content will therefore include aspects of nursing such as conflict resolution, communication and the nursing process, as well as technical components such as medication administration. The most frequent issues observed with novice nurses as identified in the literature will also be incorporated into the programme. For example, lack of knowledge about appropriate delegation, inability to interpret lab data, and poor prioritization and time management skills (Stefanski & Rossler 2009). Using participatory teaching methods
Appropriate and effective teaching strategies are essential to ensure translation of knowledge into practice (Anderson et al. 2012). In a report of nurse perceptions of continuing education programmes in Nigeria, nurse respondents desired continuing education programmes that were learner-driven and flexible, with technology-based methods used to enhance self-directed
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Pre-/post-tests Course evaluations Written exam Self-evaluation
Evaluation methods
Teaching Methods:
Assessments Respiratory Cardiac Skin/integument Interventions Oxygen therapy Pain management Blood administration Preventative Hand washing Isolation precautions Professionalism Ethics Communication Didactic lectures (70%) Case studies (10%) Group discussion (10%) Self-directed learning (10%)
Specific courses and teaching topics:
Novice – block 1
Table 1 Example of Adult Critical Care Module
Post-test Course evaluations Competency evaluation Written exam Self-evaluation
Didactic lectures (40%) Clinical simulations (40%) Self-directed learning (20%)
Critical care II Arrhythmia Congestive heart Failure Renal failure Ischaemic and Haemorrhagic stroke Thrombosis Mentoring
Critical care I Lab value Interpretation Resuscitation (Basic Life Support) Shock ECG (Electrocardiogram) interpretation Wound care Burns
Didactic lectures (50%) Case studies (10%) Group discussion (10%) Clinical simulations (20%) Self-Directed Learning (10%) Pre-/post-tests Course evaluations Competency evaluation Written exam Self-evaluation
Competent – block 3
Adv. Beginner – block 2
Post-test Course evaluations Competency evaluation Written exam Self-evaluation
Didactic lectures (40%) Clinical Simulations (40%) Self-directed learning (20%)
Critical care III Central lines Arterial lines Care of patient on ventilator Intubation – meds, rapid sequence Weaning and extubation Multisystem trauma
Proficient – block 4
Ongoing continuing education
Expert
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Table 2 Example of curriculum outline for blood administration Objectives
Content outline
Learning resources
Clinical competencies
Demonstrates the correct sequence and documentation of the steps in the blood component administration policy/procedure Pre-transfusion Transfusion Identifies five signs and symptoms of a transfusion reaction Identifies five blood components and lists one indication for each Identifies equipment needed to set up and administer blood components
Background/rationale – transfusion safety Preparation of patient/equipment Order/consent Collection of type and screen sample Requesting blood component procedure Checking blood component for any discrepancies Administering blood components: Blood donor type and compatibility Solutions and tubing Infusion rates, first-five minutes, subsequent Time out of refrigeration Documentation: Response Intake/output Equipment discard Protocol for patient needing to leave unit signs/symptoms, onset and types of reactions Steps to be taken in event of suspected transfusion reaction Nurses role in managing and reporting a suspected transfusion reaction Review of blood components: red blood cells, fresh frozen plasma, cryoprecipitate, platelets and albumin and indications for each
PowerPoint presentation Case study Guidelines for Transfusion reaction Policies and procedures on blood component administration Transfusion reaction protocol Competency evaluation Checklist
Appropriately prepare patient and environment for care of patient receiving blood components Routine care Emergent care Verbalize how to correctly perform a type and screen as per facility’s procedure Utilize correct procedures during blood component check Understand rationale for administering specific blood components to patients Verbalize appropriate solutions compatible with blood components Verbalize two timeframes nursing is responsible for when administering blood components Verbalize at least five signs and symptoms of a transfusion reaction and appropriate nursing interventions Complete the facility’s transfusion reaction form. Follow appropriate steps in reporting a suspected transfusion reaction Verbalize indications for five different blood components
Associated simulation: blood product administration.
learning (Nsemo et al. 2013). Other suggestions from the literature that have been incorporated into the BEP include, limiting the amount of didactic content in favour of participatory sessions (Rowe et al. 2005), practising tasks in the field under supervision during training or as a follow-up (Dieleman et al. 2009; Lehmann et al. 2008), using a cascade training approach (Dieleman et al. 2009), and intra-professional socialization through discussion sessions aimed at sharing strategies about how to manage workplace stress (Anderson et al. 2012). Clinical simulations are a well-documented method that provide an opportunity to assess a nurse’s ability to apply concepts to clinical situations, adapt to emerging priorities, and recognize emergency situations (Stefanski & Rossler 2009).
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Addressing resource constraints in time and scheduling
Two of the identified barriers to continuing education are time/ scheduling constraints and insufficient notice of presentations (Griscti & Jacono 2006; Nsemo et al. 2013). In the BEP, cohorts of 6–12 nurses will be created with each cohort participating in the module specific to their unit (e.g., emergency department nurses will attend the Adult Critical Care Module). Learning in groups is an excellent way to create safe, trusting, and collaborative learning environments, and promotes knowledge retention and teamwork when nurses return to their unit (Anderson et al. 2012). Each cohort will have a specific teaching day, which will be incorporated into their schedule by the nurse managers of each unit. Each block will consist of 56–72 h of instructional
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time distributed over 7–9 weeks in 8-h increments of continuing education days. Evaluating and monitoring outcomes
Evaluation and monitoring are crucial aspects of any continuing education programme. There is a noted gap in the literature regarding monitoring and long-term evaluation of continuing education programmes, which makes it difficult to objectively assess whether they result in successful outcomes (Dieleman et al. 2009). Evaluation is an essential part of the continuing education programme at HUM and includes a combination of methods. Structured observation and pre-/post-tests will assess retained knowledge of teaching sessions, whereas selfevaluations will assess more abstract areas such as perceived autonomy, job satisfaction and intent to stay (Anderson et al. 2012). The programme will also be evaluated both by participants and by an external third party. Effects on nurse retention will be assessed through self-reported intent to stay and turnover rates (i.e., length of time an employee remains in a position). Establish partnerships
Utilizing partnerships with local nursing schools, other healthcare institutions and international organizations helps increase the feasibility of implementing a continuing education programme in a low-resource setting. ZL has many existing partnerships and is adapting resources from these partners for use in the BEP. For example, HUM is currently in possession of a neonatal intensive care training curriculum that will be evaluated and modified for use in the Neonatal Critical Care Module. Early discussions with another hospital in Port-au-Prince have also introduced the possibility of acquiring a Paediatric Intensive Care training course that has already been developed by that institution. Partnerships with local nursing schools are of vital importance and will be utilized for recruitment of professors to teach modules.
Discussion Nursing continuing education is an underdeveloped and underutilized means to strengthen healthcare delivery in lowresource settings. The example from Haiti offered in our case study provides guidance for those wishing to develop similar programmes in Haiti, and low-resource settings in other countries. Our literature search found no other descriptions of comprehensive nursing continuing education programmes in a lowresource setting, so we are unable to compare our programme. Although many programmes have been described in highincome countries, the only documented nursing continuing
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education initiatives found in the literature for low-resource settings were focused on specific interventions, such as intramuscular injection (Walters & Furyk 2010). One of the main factors identified as crucial to facilitating development of the BEP was the commitment and support for nursing continuing education at both a national and institutional level. The MSPP clearly identifies continuing education for nurses as a key component of their healthcare strategy, and this commitment has been evidenced by involvement of the National Director of Nursing in meetings about the BEP. Commitment at the institutional level of HUM is reflected in the organizational structure of the hospital, which has empowered the Chief Nursing Officer and made it possible for her to allocate the necessary resources to move the project forward. Nursing is often not recognized in a management structure and lacks decision-making authority. Adequate recognition of the vital role of nursing in the health system and support for nursing continuing education at a national, organizational and institutional level is an important preceding factor for the successful development of programmes. Many health human resource initiatives carried out with the goal of improving healthcare delivery include monetary incentives such as increased wages, pensions and tuition reimbursement. In low-resource settings, financial resources are extremely limited, which constrains the use of monetary incentives and makes other less costly initiatives such as continuing education programmes more appealing. Although continuing education programmes do have inherent costs, many of the cost-intensive aspects such as curriculum development, lie in the planning phase and would only be necessary once. Potential effects of continuing education programmes on improved retention have cost-saving benefits, as high turnover is associated with high costs in training new employees. One of the limitations of this project at the present time is that programme implementation is incomplete and the first cohort of nurses has yet to complete the programme. However, the programme described can still serve as a starting point for other healthcare institutions in low-resource settings that wish to develop their own continuing education programmes.
Conclusion In the context of a global call to action on human resources for health, nursing continuing education is an important strategy for promoting nurse retention and professionalism, fostering motivation, and building the knowledge and skill of the existing nursing workforce in low-resource settings. Given that 90% of all global healthcare services are provided by nurses and midwives, strengthening care provided by this group will, by
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extension, strengthen healthcare systems as a whole by improving delivery of care, and resulting in sustained positive health outcomes for patients.
Implications for nursing and health policy Our review of existing reports suggests the need for policymakers in resource-limited settings to make greater investments in nursing continuing education as a focus of human resources for health. Despite increased recognition that health workers are critical to achieving health-related goals and fostering effective health systems, there is an inadequate amount of investment in health workers and in evaluation of education programmes directed towards them (Chopra et al. 2008). A range of research is needed to identify: (1) factors that contribute to a successful nursing continuing education programme, (2) best practices for programme development and implementation, and (3) effects of programmes on nurse retention, motivation, professionalism, and performance.
Acknowledgements We acknowledge the assistance of the nursing staff at Zanmi Lasante/Hôpital Universitaire Mirebalais, who provided information for the case study.
Author contributions MC, did data collection/analysis, and drafting of paper. MJ, did study conception and field supervision. NM, did critical revisions for important intellectual content and field supervision. LM, did drafting of paper and critical revisions for important intellectual content. JT, did supervision and critical revisions for important intellectual content. AJG, did study design, critical revisions for important intellectual content and supervision.
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