Nursing curriculum development in remote southwest Uganda L.R. Wallace
RN, DNP(c), MSN, CNS, PHN
Clinical Instructor, Dominican University of California, San Rafael, CA, USA
WALLACE L.R. (2015) Nursing curriculum development in remote southwest Uganda. International Nursing Review 62, 360–367 Purpose/Aim: To describe an intercollaborative outreach between the USA and a school of nursing in Uganda. Introduction: Ugandan nurses are essential providers of health care in remote regions. High vacancy rates in health centers impacts care in rural areas. Background: A 112-bed health center in southwest Uganda supports village health teams that visit remote villages and provides medical, surgical, and maternal-child services to a population of 250,000. A new Ugandan school of nursing has aligned with the hospital to prepare graduates to provide primary care in remote villages. A team from the USA visited the school and hospital to assess the curriculum and offer educational strategies and support to the school’s leadership. Evidence: Provision of primary health care in the developing world is a longstanding global priority. Nurses are at the center of primary care in remote regions. Educational support for advanced nursing and strategic international relationships can positively impact nursing education in both high and low-income countries. Discussion: The USA team took part in assessments, teaching, simulation, and remote village outreach. Educational strategies and modalities were shared. Conclusions: The Ugandan nursing school is established and affiliated with another Ugandan university. Standardized curriculum is in place, however continued collaboration is needed for program adaptation to accommodate the unique border region environment. Implications for Health Policy and Nursing: Intercollaborative sharing of information and resources between schools of nursing can have a direct impact on global health initiatives in both high-income and low-income countries. Keywords: International Collaboration, Curriculum Development, Nursing, Nursing Education, Primary Health Care, Remote Health Care, Uganda
Correspondence address: Leandra R. Wallace, Dominican University of California, 50 Acacia Avenue, San Rafael, CA 94901, USA; Fax: 415 257 0120; E-mail: [email protected].
Conflict of interest statement No conflict of interest has been declared by the author. Funding Funding for Vocational Training Team activities provided by Rotary International.
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Nursing Education
Nursing curriculum development Uganda
Introduction Nurses in Uganda deliver most of the rural health care (Ziegler et al. 1997). According the United Nations Population Fund (2011), Uganda has only 1.4 doctors, midwives and nurses per 1000 people. In the remote southwest region of Uganda, where this outreach is focused, there is only one registered nurse for every 40 000 people (Kellerman Foundation 2013). The need for trained nurses is crucial. The Ugandan Ministry of Health (UMH) 2010/2011–2014/2015 Health Sector Strategic Plan reports that level II health centres (HC) have the highest staff vacancy rate at 67%, with a nursing vacancy of 53%. HC II are located primarily in rural areas. There is an inequitable distribution of healthcare workers between rural and urban areas, with 70% of doctors, 80% of pharmacists and 40% of nurses and midwives working in urban areas that serve only 13% of Uganda’s population (Uganda Ministry of Health 2014). Vacancies in health care are attributed to insufficient training capacity, low wages and poor working conditions. A study by Rockers et al. (2012) highlights that in addition to higher wages, Ugandan nursing employment preferences include high quality, fully staffed health facilities, access to high quality equipment and having a supportive manager. These are not generally available in rural communities and study respondents indicated that it was unlikely that they would seek work in a rural facility. Another study by Nguyen et al. (2008) found that 70% of respondents to an anonymous survey at two major nursing schools in Uganda said it was likely that they would leave Uganda to work in the USA, the United Kingdom or another African country. Only 8% planned to stay in Uganda upon graduation. This study underscores the imperative need to recruit and educate nurses who have a desire to work in the rural areas that serve the majority of Ugandan population. The study found a direct relationship between students inclined to work in rural areas and intention; those who want to work in rural areas were less likely to report plans to emigrate and quoted both national and personal pride as part of the reason (Nguyen et al. 2008).
Background Setting
Bwindi is a remote border region in southwest Uganda. While remote, the climate is temperate and the region has some of the world’s best farmland. The result is that it is one of world’s most densely populated areas (van de Giessen 2005). This remote location is accessible primarily by vehicle on unpaved roads that are not routinely maintained. Difficulty reaching this area prevents distribution of resources such as electricity and
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fuel. Government HC exist but are poorly maintained secondary to lack of funding for personnel and supplies. Life in this remote region
There are scattered small villages and several large towns in this region. Most have no electricity and the use of fuel- or batteryoperated lanterns is common in the evening. Water is collected from wells and rivers requiring a great amount of time and effort and is routinely done by women and children. Most communities depend upon family gardens and farms for basic subsistence. Kemp & Tindiweegi (2001) describe the environment in Uganda as one in which women need to be empowered in order to increase the health of rural communities. However, women hold the primary responsibility for the nutrition of their families, to include breastfeeding, cultivating and preparing food, and obtaining water. Women often work many more hours than men and thus have no time for education and have a high likelihood of dropping out of school before they finish the requirements for higher education. The result is a reduced literacy rate for women, with a resultant shortage of nurses and nursing professors for schools of nursing. HC resources
Uganda has both publicly and privately sponsored HC. The public system is a tiered system in which patients are frequently referred to the next level of care when their needs cannot be met at a low level. HC range from I to IV and provide most of the care. A HC IV can provide high-level services such as caesarean sections and other surgical care, while an HC I may be staffed with volunteers who primarily provide community outreach services or the sale of medications when available. Above the HCs are regional and national hospitals. The private sector holds both profitable and non-profitable organizations, 70% of which fall under the umbrella of the Uganda Catholic or Uganda Protestant Medical Bureaus (Uganda Ministry of Health 2011). In 2001, a medical doctor reached out to the Batwa people as a medical missionary (Kellerman Foundation 2013). Homeless and without skills for existence outside their traditional lifestyle, the Batwa faced extinction. From humble beginnings in treating patients under a tree, a foundation was created in 2004 that supported the building of a hospital in one of the remotest areas of Africa. The 112-bed HC IV serves as a regional community hospital and now provides patient care for adults and children, maternity services, surgery, tuberculosis (TB) monitoring and treatment, HIV treatment and support in the Kanungu region. This hospital not only serves the Batwa people, but also the entire region of 250 000 people with a catchment area that is continuously growing.
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In addition to hospital services, the HC IV community hospital is home to village health teams (VHT) that visit 101 remote villages to provide education and screenings, give immunizations, conduct HIV tests and arrange treatment, assist with birth control and sell low-cost mosquito nets. Village health promoters (VHP) are lay citizens who are trained to provide specific, basic services in their own villages which are so remote they require a day’s walk to get to the hospital. The VHP model, also known as the Community Health Worker model, partly arose from the 1978 Alma-Ata Conference that concluded with a global agenda to provide ‘Health for All by the Year 2000’ (World Health Organization 1978). To meet this vision for primary health care (PHC), the concept of focused training of citizens who are vested in their own communities has grown into programmes supported at local, national and global levels all over the world, especially in emerging economies (Bender & Pitkin 1987). These programmes also support the United Nations Millennium Development Goals (MDG) of which Uganda is a participant (United Nations 2013). The vision to provide better health care in this remote region did not end with the hospital. In late 2013, an RN level nursing programme opened its doors to the first nursing students in this rural area with a vision to graduate students who have the education and skills to manage outreach clinics that serve some of the remotest and poorest areas of Africa. The school has a stated goal to prepare graduates to care for both simple and complex patients in the remote villages of the southwest region of Uganda and to increase education and outreach so that more villagers can be referred and receive care at the HC IV community hospital. The newly opened nursing school will provide education that aligns with the MDG and UMH goals, as well as with programmes already underway at the community hospital. The school campus is located within easy walking distance of the hospital, as well as several villages. Currently, the new school is affiliated with a large Christian university and utilizes standardized Ugandan curriculum which will ensure graduates are prepared to address sexual and reproductive health, child health, health education, control and prevention of communicable diseases and identification of HIV/acquired immunodeficiency syndrome (AIDS), malaria and TB. The school also has a desire to focus on community health and educate graduates to work with VHTs by providing an advanced nursing curriculum grounded in primary care principles. A grant funded the equipment and furnishings for the new school which houses its own living quarters for students and faculty, a dining room, several classrooms, a lecture hall and a skills laboratory. In addition, there was financial provision for a vocational training team (VTT) to travel Uganda to assess
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needs of the Ugandan nursing instructors, participate in intercollaborative teaching and begin development of a simulation programme in the skills laboratory. Part of the VTT’s focus was on assessment of the remote villages current clinic status and VHT outreach process with the goal of developing a plan to promote this valuable learning opportunity to the nursing students. Ultimately, the outcome of implementing a rurally focused and advanced nursing curriculum will benefit a huge region, the entire southwestern part of Uganda. Objectives of the team were to (a) assess the curriculum and offer practical teaching strategies and modalities to meet course objectives and competencies, (b) assess available resources and make recommendations for maximizing their use in the curriculum, (c) explore the role of the local VHTs and the potential to include VHT outreach as part of the community health curriculum, and (d) establish a partnership with the school and faculty in order to provide ongoing support and an intercollaborative outreach. Sources of evidence
Literature to support the development of PHC in the context of the developing world exists and has been a global focus for over 50 years. The 1978 Alma-Ata report released by the World Health Organization highlights the need for trained personnel other than physicians to provide primary care. Subsequent development of community health worker (CHW) teams has been very successful. However, their outreach is usually specific and limited in scope, which can result in fragmentation of care while also improving certain health conditions. While there is ample evidence to support CHW models, there is limited literature that describes nurses working as PHC providers as part of these teams, despite the vision that nurses would be largely involved with training and supervising health workers (World Health Organization 1984). Mackey et al. (2013) address the lack of PHC principles in nursing education and the need for curriculum changes that incorporate PHC across the curriculum. Several countries already include PHC as a discrete course within the nursing programme, but development of a comprehensive curriculum has been elusive. PHC has an emphasis on social rather than biological or medical models of health and is congruent with the mission of nursing; nursing education, however, is currently grounded in science, pharmacology and a medical-surgical approach to health. Dick et al. (2007) describe an intervention in South Africa in which primary care nurses partnered with and led a team of trained lay health workers (LHW) to help treat and prevent TB among poor farm workers. They were effective in early identification, treatment and cost containment. Their holistic approach to a complex disease and use of current biomedical treatment is
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impressive; a team of three, including two trained nurses, tackled a 1661-km area with 211 rural farming communities and were able to lead farm-based LHWs with a resultant 74% reduction in cost per treatment case and a completion of TB treatment rate 18.7% higher on farms with LHW intervention (Dick et al. 2007). Nalwadda et al. (2013) used a focused CHW training model with 61 literate trainees in rural Uganda. Training was conducted on the identification of sick newborns. At the end of training, they had a high level of competence and could identify and refer sick infants if needed. Ongoing success of this programme is attributed to the support of the CHW skills by direct observation, debriefing and monthly meetings with supervisory health workers who maintain the programme. While simple tasks can be assigned to lay workers, ongoing supervision, management and education is a key in successful patient outcomes. This study also highlights the importance of high-level communication between the CHWs and other team members so that care is appropriate. Decroo et al. (2013) underscore the need to have local health teams that incorporate task shifting and have a variety of skill mixes to provide care in underserved areas. Palazuelos et al. (2013) describe a framework developed by Partners in Health, which operates outside of Boston, Massachusetts. This framework is a contemporary conceptual model that provides guidance in the construction and maintenance of high-performing CHW models. Five main components are described, including supervision of CHWs, partnership between collaborative entities, incentives for CHWs (which are sometimes volunteers), choice about CHW recruitment, training and retention and education of the CHWs once they are identified. The 5-SPICE (supervise, partner, incentive, choice, and education) model addresses five main principles: (1) access and trust in the primary care system, (2) removing barriers to access by providing education and free health care, (3) mutual respect among community partnerships, (4) recognition of root cause of disease from the socio-economic perspective, and (5) the right to health care for the poor can be best met through the public sector of health care (Palazuelos et al. 2013). This informative study provides other valuable insight into the process of creating a successful CHW programme, such as the need for self-sustaining societies if volunteers are needed, and the process by which CHW programmes are initiated and maintained. There is worldwide recognition that nursing has become increasingly complex and that there is great need for nurses to work independently while applying innovational practices that are cost-effective and take into consideration low resources (Dunlap 2013). The current model of education in Uganda is different from the Western models and is primarily didactic
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using teacher-centred pedagogic methods (Lovett & Gidman 2011). Nurses are primarily trained in hospitals and in the urban setting, with limited exposure to nursing in the community (Kemp & Tindiweegi 2001). There is an emphasis on memorization vs. application of theoretical concepts and higher-level reasoning and critical thinking. It is important to note that not all cultures approach health care with Western definitions of nursing and caring, thus applying Western theory and constructs is a challenge in many instances when attempting international nursing education support (Dunlap 2013). Caution must be taken when emphasizing these elements outside Western culture with great attention given to cultural competence. International nursing partnerships are common, however, research that supports collaboration that is beneficial to both low-income countries (LICs) and high-income countries (HICs) is lacking. A meta-analysis by George & Meadows-Oliver (2013) found only nine research articles that met strict research criteria that includes authors from both HICs and LICs, as well as meeting criteria for international nursing clinical, education and research partnerships. The ‘counterpart concept’ proposed by DeSantis (1995) was the theoretical concept for this review; this structure forms a basis for assessing international collaborations and includes four concepts that are important in international collaboration. The constructs offered by DeSantis are of great value to this project, and while other literature is reviewed, this framework can add value and clarity. According to DeSantis (1995), the first important concept is to negate the need for the donor group, which is the ability of the HIC to create a sustainable environment for the LIC that phases out reliance on the HIC. The second concept is to address the needs, resources and potential of the LICs. The third concept is to address the sociocultural, political and economic elements that affect collaboration and planning when a nursing partnership is desired. Finally, the fourth concept focuses upon the development of nurses to their fullest potential. Nurses from both the HICs and LICs should benefit from the collaboration and focus should not be the flow of information from the HIC to the LIC without recognition that LICs have something to offer HICs.
Discussion VTT activities
The goal of the VTT was to partner with nursing leadership at the newly established nursing school to help support the school’s mission and vision to equip students with effective skills in nursing and midwifery which will improve health care and drastically reduce morbidity and mortality. The VTT was
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comprised of three professional nurses from the USA who have specific background in nursing education and clinical expertise in rural and community environments. Preparation for travel to Uganda included multiple face-to-face meetings of team members, as well as continuous email and phone communication with the Ugandan nursing school director. Topics for education, on-site training, meeting agendas and plans for a joint consortium on the topic of ‘Excellence in Nursing’ were all accomplished prior to travel. There was great attention to cultural differences, with mutual respect and consideration observed during all planning and communication. Assessment activities
The VTT spent 3 weeks in the southwest corner of Uganda. Tours of the school and hospital occurred on the first day, with the second day committed to meeting the nursing faculty leadership. Clarifications around teaching structure and pedagogy were made; an important finding was that most classes are taught by the nursing school director with support from hospital staff, both medical and nursing. Visiting faculty also occasionally lead lectures or assist with teaching. Classes are didactic and the use of current technology such as electronic whiteboards and access to iPads by the students is standard. There is a library with current textbooks available for the major courses. The school houses a nursing skills and simulation laboratory with both stations and basic supplies for practice of skills in addition to both standard adult and infant mannequins as well as a birthing mannequin model. Classes are attended for the first 12 weeks of the semester, with the final 4 weeks dedicated to clinical time in the hospital units. It was also discovered that the school has intercollaborative relationships with multiple nursing schools in the USA to support various activities such as faculty support and ultrasound education which was unknown when the VTT made its visit. VHT
The VTT had the opportunity to travel with the VHT to several remote villages to assess VHT activities and the potential for student participation. Multiple trips highlighted a focus on HIV testing and counselling of the Batwa people. Rapid HIV tests are performed in the field by highly trained and experienced VHPs, with follow-up counselling and referral for free treatment at the local HC IV. Education is provided on site to all villagers, with testing offered for individuals starting at age 12, with age 14 being more average. While one village was only minutes from the HC, others were 2 h away over poorly maintained dirt roads. All sites are reached with a Land Cruiser ambulance that is wellequipped to drive over harsh terrain.
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One outreach day revealed a collaborative health event attended by representatives from the UMH, VHTs from the HC IV and midwives from the regional HC III. Services offered included adult male circumcision, female family planning counselling and opportunity for access to contraception, newborn weight checks and immunizations, HIV testing and dental procedures by the HC IV dentist. Approximately 250 local villagers attended to receive the offered services, most of which were offered for free. The faculty also spent a large amount of time in the hospital with the nursing students and clinical instructors. The focus was on the approach to clinical teaching in a resource-poor environment, as well as the teaching process of the clinical instructors who are staff nurses in the hospital and who had to maintain a patient load as well as instruct the students. In addition to time in the field and hospital, a simulation was organized. The concept of simulation, while known by some of the medical doctors and used in some medical training in Africa, is not widely used in Uganda. A paediatric scenario was developed and written in conjunction with the lead paediatrician, during which concepts of simulation and use of both standardized and customized templates were shared. A student was chosen to be the nurse and had time to prepare to see a dehydrated paediatric infant. After a didactic class on paediatric dehydration, students moved into the skills and simulation laboratory where a volunteer presented to clinic with a sick neonate and the student proceeded to perform a history and physical examination with direction from both the VTT faculty and the hospital paediatrician. The laboratory was set up by a VTT member who had help from several students so that the process could be seen from beginning to end and shared with the class. Finally, a collaborative nursing symposium was held at the nursing school. This programme had a theme of ‘Excellence in Nursing Education: Excellence with Compassion’ and was attended by nursing faculty and leaders from Uganda, the USA, Canada and the United Kingdom. Presentations by faculty from multiple Ugandan schools of nursing, the VTT and the Ugandan Nursing Council highlighted the symposium. Topics such as the role of technology in nursing education, community-based care and nursing and interprofessional communication were presented, as well as history of the hospital and an overview of nursing education throughout Uganda which was presented by the Ugandan Nursing Council. Impressions and recommendations
Over the course of the 3 weeks, multiple meetings held with the Ugandan nursing school director and assistant focused upon sharing teaching experiences and observations, ideas for
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advancing the goals of the school and exploring the potential for ongoing collaboration with the university in the USA. The US team learned about the Ugandan nursing curriculum and student progression, their collaboration with other agencies both in Uganda and the USA and the difficulty attracting and retaining both nursing faculty and hospital staff to this remote region. The Ugandan team also learned about some of the current modalities for teaching and optimizing student learning opportunities in the USA, such as simulation, and the shared difficulty in retaining nursing faculty in a competitive healthcare environment. Observations made both in the hospital and field contributed greatly in understanding the challenges the nursing school are facing, while also highlighting the success of the school to attract students and present a rigorous curriculum. Major challenges include finding qualified faculty to help with classroom teaching, how to transport students to other villages for exposure to remote HC II and III and how to educate students in a resource-poor environment where they will learn procedures didactically and in a skills laboratory that do not always have actual supplies available to perform assessments and procedures. Upon collaboration with the Ugandan team, several recommendations and possible solutions were discussed. Because of the great emphasis on remote clinic and rural outreach, the school has two community health courses and it was recommended that the Ugandan nursing students do clinical rotations with the VHTs. During VHT outreach, it is common for 20–50 villagers to congregate. Many have health issues that could be assessed while waiting for HIV testing and the other focused services the VHPs provide. Students will have ample opportunity to engage with villagers and perform assessments, physical exams, basic care, such as wound care, and to provide education grounded in public health principles and prevention. Recognition of more serious conditions can result in referral to the HC IV. Ultimately, as students graduate, an RN could be sent with the VHTs to provide a greater skills mix with the objective of providing more care in the villages, prescription of basic medications and performing minor procedures. The school is aligned with the HC IV community hospital, as well as all the VHTs, so the structure for students to accompany VHTs already exists but primary care objectives and competencies for this clinical experience need to be developed and is ongoing. To help alleviate the stress on the nursing director who is also teaching most of the classes, affiliate faculty status was offered by the US university and was accepted by the Ugandan director. In keeping with the counterpart concept model, the goal is to create a long-term collaboration between the two schools, with the initial objective being to provide foundational information
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and communications technology (ICT) support to the Ugandan director and faculty. A trial of collaboration between the US university and the Ugandan university will occur during the spring of 2015, with a focus on the community health clinical of the Ugandan students and the use of ICT with the goal of integrating Ugandan student classroom experiences with their clinical experiences. The Ugandan school decided to place students with the VHTs but was uncertain about how to create a rigorous clinical experience without resources. To address this, an Educational Wiki page was developed to post and share documents such as health assessment forms, online tutorials and teaching plans for the students to utilize. This page can be accessed by both US and Ugandan faculty. The Ugandan faculty can further decide to open it to their nursing students or to use the shared documents to create their own Wiki page for their students. It is important to note that there is often a misalignment between westernized ICT systems and those of the emerging world where poverty, illiteracy and poor infrastructure are major barriers to adoption of technology (Abbott & Coenen 2008). However, health communications with the use of ICT have been successful in many developing countries such as Kenya, Malawi, Rwanda and Haiti. The ease of use provided by platforms, such as Wiki, has increased the sharing of educational and medical resources around the world (Boulos et al. 2006). According to Boulos et al. (2006), a Wiki is a website that contains content that can be edited and used for obtaining and sharing knowledge, as well as engaging in collaborative engagement. They require minimal skill to establish and maintain, making them ideal for individuals of all educational levels. They are also extremely useful for clinicians in remote or rural areas that may be isolated. The use of a Wiki page to create a social and professional relationship can provide much needed support, as well as encourage active involvement with engaged learning. Thus, a Wiki page was chosen because of the ease of use and the ability of the Ugandan faculty to share this tool with students and with the objective of mentoring Ugandan faculty in the use of an information management system that is easy to access. In addition, a community health clinical syllabus was shared to give the Ugandan faculty ideas for their clinical experiences. The Ugandan school director will also be paired with a US faculty to be mentored and she will prepare a class for presentation to the US students. At the end of the spring semester, feedback from both the Ugandan and US teams will be solicited to determine the success of the initial collaboration and long-term objectives. Inherent to the success of this collaboration will be recruitment of US faculty to assist the Ugandan faculty over the next several semesters; this process has started and will be ongoing during the spring of 2015.
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Practical solutions to some of the supply issues noted in the clinical areas of the hospital were also made. Many items are purchased or donated without regard to actual need of the hospital and Ugandan staff were not always aware of alternative supplies and equipment that can be used. A list of high-need supplies and low-cost equipment items was generated in conjunction with hospital nursing administration to be reviewed so that appropriate changes in ordering can be made. Logistical items, such as storage and accessibility of supplies, were also addressed with recommendations resulting in changes beneficial to staff and students at both the hospital and in the nursing school skills laboratory.
issue that impacts populations that can be oceans apart. Thoughtful planning and systematic sharing and application of resources have the potential to assist schools of nursing in developing nations with implementation of current technology and practices. In addition, developing countries have a great desire to share their knowledge and application of disease management that Western health systems are not familiar with. Ultimately, intercollaborative sharing of information and resources between schools of nursing can have direct impact on global health initiatives and health care delivery by nurses in both HICs and LICs.
References Conclusions The new nursing school in southwest Uganda will provide education that aligns with the MDG and UMH goals, as well as with programmes already underway at the local HC IV community hospital. Currently, the school is affiliated with a major university and will utilize standardized Ugandan curriculum which will ensure graduates are prepared to address sexual and reproductive health, child health, health education, control and prevention of communicable diseases and identification of HIV/ AIDS, malaria and TB. School leadership is in place and has support from the Ugandan Nursing Council. This outreach addresses the school’s desire to further prepare the nursing school graduates to independently work and provide care in remote village clinics, as well as to possibly lead VHTs by providing an advanced nursing curriculum that is grounded in primary care principles. Curriculum development is being coordinated in a collaborative fashion with Ugandan leadership. Focus is on the specific needs of the Ugandan faculty and nursing students. Ultimately, the outcome of implementing a remotely focused and advanced nursing curriculum will benefit a huge region, the entire southwestern part of Uganda. In order to address the school’s vision to provide nurses trained in advanced techniques and primary care to this remote region, support from the VTT and affiliated universities will be formal and ongoing. Progress thus far is promising, with both the hospital and Ugandan school of nursing having a direct relationship with multiple supportive entities in the USA. Formal plans for ongoing support are in progress. Implications for health policy
Nurses in the developing world have great need and a desire to collaborate with Western universities and hospitals. They desire to be active in the development of foundational infrastructure and evidence-based practices that are both culturally relevant and practical for the difficult environments in which they practice. As the recent Ebola epidemic highlights, health is a global
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Abbott, P.A. & Coenen, A. (2008) Globalization and advances in information and communication technologies: the impact on nursing and health. Nursing Outlook, 56 (5), 238–248. Bender, D.E. & Pitkin, K. (1987) Bridging the gap: the village health worker as the cornerstone of the primary health care model. Social Sciences Medicine, 24 (6), 515–528. Boulos, M.N.K., Maramba, I. & Wheeler, S. (2006) Wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. BMC Medical Education, 6, 41. Decroo, T., et al. (2013) Community-based antiretroviral therapy programs can overcome barriers to retention of patients and decongest health services in sub-Saharan Africa: a systematic review. International Health, 5, 169–179. DeSantis, L. (1995) A model for counterparts in international nursing. International Journal of Nursing Studies, 12 (2), 198–209. Dick, J., Clarke, M., van Zyl, H. & Daniels, K. (2007) Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector. International Nursing Review, 54, 383–390. Dunlap, R.K. (2013) Nursing theory and the clinical gaze: discovery in teaching theory across a cultural divide. Nursing Science Quarterly, 26 (2), 176–180. George, E.K. & Meadows-Oliver, M. (2013) Searching for collaboration in international nursing partnerships: a literature review. International Nursing Review, 60, 31–36. Kellerman Foundation (2013). Providing Hope and Health in Uganda. Available at: http://www.kellermanfoundation.org (accessed 3 May 2014). Kemp, J. & Tindiweegi, J. (2001) Nurse education in Mbarara, Uganda. Journal of Advanced Nursing, 33 (1), 8–12. Lovett, W. & Gidman, J. (2011) Reflecting on the learning experiences of student nurses in rural Uganda. British Journal of Community Nursing, 16 (4), 191–195. Mackey, S., Hatcher, D., Happell, B. & Cleary, M. (2013) Primary health care as a philosophical and practical framework for nursing education: rhetoric or reality? Contemporary Nurse, 45 (1), 79–84. Nalwadda, C.K., et al. (2013) Community health workers – a resource for identification and referral of sick newborns in rural Uganda. Tropical Medicine and International Health, 18 (7), 898–906.
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Nguyen, L., et al. (2008) Intent to migrate among nursing students in Uganda: measures of the brain drain in the next generation of health professionals. Human Resources for Health, 6, 5. Palazuelos, D., et al. (2013) 5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting. Global Health Action, 6, 19658. Rockers, P.C., et al. (2012) Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment. BMC Health Services Research, 12, 212. Uganda Ministry of Health (2011). Uganda health system assessment 2011. Available at health.go.ug/docs/hsa.pdf (accessed 3 May 2014). Uganda Ministry of Health (2014). Health Sector Strategic Plan (HSSP) III, 2010/11–2014/15. Available at: http://www.health.go.ug/docs/HSSP_III _2010.pdf (accessed 3 May 2014). United Nations (2013). Overseas Development Institute Uganda Case Study for the MDG Gap Task Force Report. Available at: http://www.un.org/en/ Development/desa/policy/MDG_gap2010/mdggap_uganda_casestudy .pdf (accessed 3 May 2014).
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United Nations Population Fund (2011). Uganda Country Profile. Available at: http://www.unfpa.org/public/ (accessed 3 May 2014). van de Giessen, E. (2005). Peace Park Amid Violence? Institute for Environmental Security. Available at: http://www.envirosecurity.org/ (accessed 15 June 2014). World Health Organization (1978). Declaration of the Alma-Ata report from the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Available at: http://www.who.int/publications/ almaataDeclarationen.pdf?ua=1 (accessed 3 May 2014). World Health Organization (1984) Education and Training of Nurse Teachers and Managers with Special Regard to Primary Health Care. World Health Organization, Geneva. Available at: http://www.whqlibdoc .who.int/trs/WHO_TRS_708.pdf (accessed 3 May 2014). Ziegler, P.B., Anyango, H. & Ziegler, H.D. (1997) The need for leadership and management training for community nurses: results of a Ugandan district health nurse survey. Journal of Community Health Nursing, 14 (2), 119–130.
RN, DNP(c), MSN, CNS, PHN
Clinical Instructor, Dominican University of California, San Rafael, CA, USA
WALLACE L.R. (2015) Nursing curriculum development in remote southwest Uganda. International Nursing Review 62, 360–367 Purpose/Aim: To describe an intercollaborative outreach between the USA and a school of nursing in Uganda. Introduction: Ugandan nurses are essential providers of health care in remote regions. High vacancy rates in health centers impacts care in rural areas. Background: A 112-bed health center in southwest Uganda supports village health teams that visit remote villages and provides medical, surgical, and maternal-child services to a population of 250,000. A new Ugandan school of nursing has aligned with the hospital to prepare graduates to provide primary care in remote villages. A team from the USA visited the school and hospital to assess the curriculum and offer educational strategies and support to the school’s leadership. Evidence: Provision of primary health care in the developing world is a longstanding global priority. Nurses are at the center of primary care in remote regions. Educational support for advanced nursing and strategic international relationships can positively impact nursing education in both high and low-income countries. Discussion: The USA team took part in assessments, teaching, simulation, and remote village outreach. Educational strategies and modalities were shared. Conclusions: The Ugandan nursing school is established and affiliated with another Ugandan university. Standardized curriculum is in place, however continued collaboration is needed for program adaptation to accommodate the unique border region environment. Implications for Health Policy and Nursing: Intercollaborative sharing of information and resources between schools of nursing can have a direct impact on global health initiatives in both high-income and low-income countries. Keywords: International Collaboration, Curriculum Development, Nursing, Nursing Education, Primary Health Care, Remote Health Care, Uganda
Correspondence address: Leandra R. Wallace, Dominican University of California, 50 Acacia Avenue, San Rafael, CA 94901, USA; Fax: 415 257 0120; E-mail: [email protected].
Conflict of interest statement No conflict of interest has been declared by the author. Funding Funding for Vocational Training Team activities provided by Rotary International.
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Nursing Education
Nursing curriculum development Uganda
Introduction Nurses in Uganda deliver most of the rural health care (Ziegler et al. 1997). According the United Nations Population Fund (2011), Uganda has only 1.4 doctors, midwives and nurses per 1000 people. In the remote southwest region of Uganda, where this outreach is focused, there is only one registered nurse for every 40 000 people (Kellerman Foundation 2013). The need for trained nurses is crucial. The Ugandan Ministry of Health (UMH) 2010/2011–2014/2015 Health Sector Strategic Plan reports that level II health centres (HC) have the highest staff vacancy rate at 67%, with a nursing vacancy of 53%. HC II are located primarily in rural areas. There is an inequitable distribution of healthcare workers between rural and urban areas, with 70% of doctors, 80% of pharmacists and 40% of nurses and midwives working in urban areas that serve only 13% of Uganda’s population (Uganda Ministry of Health 2014). Vacancies in health care are attributed to insufficient training capacity, low wages and poor working conditions. A study by Rockers et al. (2012) highlights that in addition to higher wages, Ugandan nursing employment preferences include high quality, fully staffed health facilities, access to high quality equipment and having a supportive manager. These are not generally available in rural communities and study respondents indicated that it was unlikely that they would seek work in a rural facility. Another study by Nguyen et al. (2008) found that 70% of respondents to an anonymous survey at two major nursing schools in Uganda said it was likely that they would leave Uganda to work in the USA, the United Kingdom or another African country. Only 8% planned to stay in Uganda upon graduation. This study underscores the imperative need to recruit and educate nurses who have a desire to work in the rural areas that serve the majority of Ugandan population. The study found a direct relationship between students inclined to work in rural areas and intention; those who want to work in rural areas were less likely to report plans to emigrate and quoted both national and personal pride as part of the reason (Nguyen et al. 2008).
Background Setting
Bwindi is a remote border region in southwest Uganda. While remote, the climate is temperate and the region has some of the world’s best farmland. The result is that it is one of world’s most densely populated areas (van de Giessen 2005). This remote location is accessible primarily by vehicle on unpaved roads that are not routinely maintained. Difficulty reaching this area prevents distribution of resources such as electricity and
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fuel. Government HC exist but are poorly maintained secondary to lack of funding for personnel and supplies. Life in this remote region
There are scattered small villages and several large towns in this region. Most have no electricity and the use of fuel- or batteryoperated lanterns is common in the evening. Water is collected from wells and rivers requiring a great amount of time and effort and is routinely done by women and children. Most communities depend upon family gardens and farms for basic subsistence. Kemp & Tindiweegi (2001) describe the environment in Uganda as one in which women need to be empowered in order to increase the health of rural communities. However, women hold the primary responsibility for the nutrition of their families, to include breastfeeding, cultivating and preparing food, and obtaining water. Women often work many more hours than men and thus have no time for education and have a high likelihood of dropping out of school before they finish the requirements for higher education. The result is a reduced literacy rate for women, with a resultant shortage of nurses and nursing professors for schools of nursing. HC resources
Uganda has both publicly and privately sponsored HC. The public system is a tiered system in which patients are frequently referred to the next level of care when their needs cannot be met at a low level. HC range from I to IV and provide most of the care. A HC IV can provide high-level services such as caesarean sections and other surgical care, while an HC I may be staffed with volunteers who primarily provide community outreach services or the sale of medications when available. Above the HCs are regional and national hospitals. The private sector holds both profitable and non-profitable organizations, 70% of which fall under the umbrella of the Uganda Catholic or Uganda Protestant Medical Bureaus (Uganda Ministry of Health 2011). In 2001, a medical doctor reached out to the Batwa people as a medical missionary (Kellerman Foundation 2013). Homeless and without skills for existence outside their traditional lifestyle, the Batwa faced extinction. From humble beginnings in treating patients under a tree, a foundation was created in 2004 that supported the building of a hospital in one of the remotest areas of Africa. The 112-bed HC IV serves as a regional community hospital and now provides patient care for adults and children, maternity services, surgery, tuberculosis (TB) monitoring and treatment, HIV treatment and support in the Kanungu region. This hospital not only serves the Batwa people, but also the entire region of 250 000 people with a catchment area that is continuously growing.
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In addition to hospital services, the HC IV community hospital is home to village health teams (VHT) that visit 101 remote villages to provide education and screenings, give immunizations, conduct HIV tests and arrange treatment, assist with birth control and sell low-cost mosquito nets. Village health promoters (VHP) are lay citizens who are trained to provide specific, basic services in their own villages which are so remote they require a day’s walk to get to the hospital. The VHP model, also known as the Community Health Worker model, partly arose from the 1978 Alma-Ata Conference that concluded with a global agenda to provide ‘Health for All by the Year 2000’ (World Health Organization 1978). To meet this vision for primary health care (PHC), the concept of focused training of citizens who are vested in their own communities has grown into programmes supported at local, national and global levels all over the world, especially in emerging economies (Bender & Pitkin 1987). These programmes also support the United Nations Millennium Development Goals (MDG) of which Uganda is a participant (United Nations 2013). The vision to provide better health care in this remote region did not end with the hospital. In late 2013, an RN level nursing programme opened its doors to the first nursing students in this rural area with a vision to graduate students who have the education and skills to manage outreach clinics that serve some of the remotest and poorest areas of Africa. The school has a stated goal to prepare graduates to care for both simple and complex patients in the remote villages of the southwest region of Uganda and to increase education and outreach so that more villagers can be referred and receive care at the HC IV community hospital. The newly opened nursing school will provide education that aligns with the MDG and UMH goals, as well as with programmes already underway at the community hospital. The school campus is located within easy walking distance of the hospital, as well as several villages. Currently, the new school is affiliated with a large Christian university and utilizes standardized Ugandan curriculum which will ensure graduates are prepared to address sexual and reproductive health, child health, health education, control and prevention of communicable diseases and identification of HIV/acquired immunodeficiency syndrome (AIDS), malaria and TB. The school also has a desire to focus on community health and educate graduates to work with VHTs by providing an advanced nursing curriculum grounded in primary care principles. A grant funded the equipment and furnishings for the new school which houses its own living quarters for students and faculty, a dining room, several classrooms, a lecture hall and a skills laboratory. In addition, there was financial provision for a vocational training team (VTT) to travel Uganda to assess
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needs of the Ugandan nursing instructors, participate in intercollaborative teaching and begin development of a simulation programme in the skills laboratory. Part of the VTT’s focus was on assessment of the remote villages current clinic status and VHT outreach process with the goal of developing a plan to promote this valuable learning opportunity to the nursing students. Ultimately, the outcome of implementing a rurally focused and advanced nursing curriculum will benefit a huge region, the entire southwestern part of Uganda. Objectives of the team were to (a) assess the curriculum and offer practical teaching strategies and modalities to meet course objectives and competencies, (b) assess available resources and make recommendations for maximizing their use in the curriculum, (c) explore the role of the local VHTs and the potential to include VHT outreach as part of the community health curriculum, and (d) establish a partnership with the school and faculty in order to provide ongoing support and an intercollaborative outreach. Sources of evidence
Literature to support the development of PHC in the context of the developing world exists and has been a global focus for over 50 years. The 1978 Alma-Ata report released by the World Health Organization highlights the need for trained personnel other than physicians to provide primary care. Subsequent development of community health worker (CHW) teams has been very successful. However, their outreach is usually specific and limited in scope, which can result in fragmentation of care while also improving certain health conditions. While there is ample evidence to support CHW models, there is limited literature that describes nurses working as PHC providers as part of these teams, despite the vision that nurses would be largely involved with training and supervising health workers (World Health Organization 1984). Mackey et al. (2013) address the lack of PHC principles in nursing education and the need for curriculum changes that incorporate PHC across the curriculum. Several countries already include PHC as a discrete course within the nursing programme, but development of a comprehensive curriculum has been elusive. PHC has an emphasis on social rather than biological or medical models of health and is congruent with the mission of nursing; nursing education, however, is currently grounded in science, pharmacology and a medical-surgical approach to health. Dick et al. (2007) describe an intervention in South Africa in which primary care nurses partnered with and led a team of trained lay health workers (LHW) to help treat and prevent TB among poor farm workers. They were effective in early identification, treatment and cost containment. Their holistic approach to a complex disease and use of current biomedical treatment is
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impressive; a team of three, including two trained nurses, tackled a 1661-km area with 211 rural farming communities and were able to lead farm-based LHWs with a resultant 74% reduction in cost per treatment case and a completion of TB treatment rate 18.7% higher on farms with LHW intervention (Dick et al. 2007). Nalwadda et al. (2013) used a focused CHW training model with 61 literate trainees in rural Uganda. Training was conducted on the identification of sick newborns. At the end of training, they had a high level of competence and could identify and refer sick infants if needed. Ongoing success of this programme is attributed to the support of the CHW skills by direct observation, debriefing and monthly meetings with supervisory health workers who maintain the programme. While simple tasks can be assigned to lay workers, ongoing supervision, management and education is a key in successful patient outcomes. This study also highlights the importance of high-level communication between the CHWs and other team members so that care is appropriate. Decroo et al. (2013) underscore the need to have local health teams that incorporate task shifting and have a variety of skill mixes to provide care in underserved areas. Palazuelos et al. (2013) describe a framework developed by Partners in Health, which operates outside of Boston, Massachusetts. This framework is a contemporary conceptual model that provides guidance in the construction and maintenance of high-performing CHW models. Five main components are described, including supervision of CHWs, partnership between collaborative entities, incentives for CHWs (which are sometimes volunteers), choice about CHW recruitment, training and retention and education of the CHWs once they are identified. The 5-SPICE (supervise, partner, incentive, choice, and education) model addresses five main principles: (1) access and trust in the primary care system, (2) removing barriers to access by providing education and free health care, (3) mutual respect among community partnerships, (4) recognition of root cause of disease from the socio-economic perspective, and (5) the right to health care for the poor can be best met through the public sector of health care (Palazuelos et al. 2013). This informative study provides other valuable insight into the process of creating a successful CHW programme, such as the need for self-sustaining societies if volunteers are needed, and the process by which CHW programmes are initiated and maintained. There is worldwide recognition that nursing has become increasingly complex and that there is great need for nurses to work independently while applying innovational practices that are cost-effective and take into consideration low resources (Dunlap 2013). The current model of education in Uganda is different from the Western models and is primarily didactic
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using teacher-centred pedagogic methods (Lovett & Gidman 2011). Nurses are primarily trained in hospitals and in the urban setting, with limited exposure to nursing in the community (Kemp & Tindiweegi 2001). There is an emphasis on memorization vs. application of theoretical concepts and higher-level reasoning and critical thinking. It is important to note that not all cultures approach health care with Western definitions of nursing and caring, thus applying Western theory and constructs is a challenge in many instances when attempting international nursing education support (Dunlap 2013). Caution must be taken when emphasizing these elements outside Western culture with great attention given to cultural competence. International nursing partnerships are common, however, research that supports collaboration that is beneficial to both low-income countries (LICs) and high-income countries (HICs) is lacking. A meta-analysis by George & Meadows-Oliver (2013) found only nine research articles that met strict research criteria that includes authors from both HICs and LICs, as well as meeting criteria for international nursing clinical, education and research partnerships. The ‘counterpart concept’ proposed by DeSantis (1995) was the theoretical concept for this review; this structure forms a basis for assessing international collaborations and includes four concepts that are important in international collaboration. The constructs offered by DeSantis are of great value to this project, and while other literature is reviewed, this framework can add value and clarity. According to DeSantis (1995), the first important concept is to negate the need for the donor group, which is the ability of the HIC to create a sustainable environment for the LIC that phases out reliance on the HIC. The second concept is to address the needs, resources and potential of the LICs. The third concept is to address the sociocultural, political and economic elements that affect collaboration and planning when a nursing partnership is desired. Finally, the fourth concept focuses upon the development of nurses to their fullest potential. Nurses from both the HICs and LICs should benefit from the collaboration and focus should not be the flow of information from the HIC to the LIC without recognition that LICs have something to offer HICs.
Discussion VTT activities
The goal of the VTT was to partner with nursing leadership at the newly established nursing school to help support the school’s mission and vision to equip students with effective skills in nursing and midwifery which will improve health care and drastically reduce morbidity and mortality. The VTT was
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comprised of three professional nurses from the USA who have specific background in nursing education and clinical expertise in rural and community environments. Preparation for travel to Uganda included multiple face-to-face meetings of team members, as well as continuous email and phone communication with the Ugandan nursing school director. Topics for education, on-site training, meeting agendas and plans for a joint consortium on the topic of ‘Excellence in Nursing’ were all accomplished prior to travel. There was great attention to cultural differences, with mutual respect and consideration observed during all planning and communication. Assessment activities
The VTT spent 3 weeks in the southwest corner of Uganda. Tours of the school and hospital occurred on the first day, with the second day committed to meeting the nursing faculty leadership. Clarifications around teaching structure and pedagogy were made; an important finding was that most classes are taught by the nursing school director with support from hospital staff, both medical and nursing. Visiting faculty also occasionally lead lectures or assist with teaching. Classes are didactic and the use of current technology such as electronic whiteboards and access to iPads by the students is standard. There is a library with current textbooks available for the major courses. The school houses a nursing skills and simulation laboratory with both stations and basic supplies for practice of skills in addition to both standard adult and infant mannequins as well as a birthing mannequin model. Classes are attended for the first 12 weeks of the semester, with the final 4 weeks dedicated to clinical time in the hospital units. It was also discovered that the school has intercollaborative relationships with multiple nursing schools in the USA to support various activities such as faculty support and ultrasound education which was unknown when the VTT made its visit. VHT
The VTT had the opportunity to travel with the VHT to several remote villages to assess VHT activities and the potential for student participation. Multiple trips highlighted a focus on HIV testing and counselling of the Batwa people. Rapid HIV tests are performed in the field by highly trained and experienced VHPs, with follow-up counselling and referral for free treatment at the local HC IV. Education is provided on site to all villagers, with testing offered for individuals starting at age 12, with age 14 being more average. While one village was only minutes from the HC, others were 2 h away over poorly maintained dirt roads. All sites are reached with a Land Cruiser ambulance that is wellequipped to drive over harsh terrain.
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One outreach day revealed a collaborative health event attended by representatives from the UMH, VHTs from the HC IV and midwives from the regional HC III. Services offered included adult male circumcision, female family planning counselling and opportunity for access to contraception, newborn weight checks and immunizations, HIV testing and dental procedures by the HC IV dentist. Approximately 250 local villagers attended to receive the offered services, most of which were offered for free. The faculty also spent a large amount of time in the hospital with the nursing students and clinical instructors. The focus was on the approach to clinical teaching in a resource-poor environment, as well as the teaching process of the clinical instructors who are staff nurses in the hospital and who had to maintain a patient load as well as instruct the students. In addition to time in the field and hospital, a simulation was organized. The concept of simulation, while known by some of the medical doctors and used in some medical training in Africa, is not widely used in Uganda. A paediatric scenario was developed and written in conjunction with the lead paediatrician, during which concepts of simulation and use of both standardized and customized templates were shared. A student was chosen to be the nurse and had time to prepare to see a dehydrated paediatric infant. After a didactic class on paediatric dehydration, students moved into the skills and simulation laboratory where a volunteer presented to clinic with a sick neonate and the student proceeded to perform a history and physical examination with direction from both the VTT faculty and the hospital paediatrician. The laboratory was set up by a VTT member who had help from several students so that the process could be seen from beginning to end and shared with the class. Finally, a collaborative nursing symposium was held at the nursing school. This programme had a theme of ‘Excellence in Nursing Education: Excellence with Compassion’ and was attended by nursing faculty and leaders from Uganda, the USA, Canada and the United Kingdom. Presentations by faculty from multiple Ugandan schools of nursing, the VTT and the Ugandan Nursing Council highlighted the symposium. Topics such as the role of technology in nursing education, community-based care and nursing and interprofessional communication were presented, as well as history of the hospital and an overview of nursing education throughout Uganda which was presented by the Ugandan Nursing Council. Impressions and recommendations
Over the course of the 3 weeks, multiple meetings held with the Ugandan nursing school director and assistant focused upon sharing teaching experiences and observations, ideas for
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advancing the goals of the school and exploring the potential for ongoing collaboration with the university in the USA. The US team learned about the Ugandan nursing curriculum and student progression, their collaboration with other agencies both in Uganda and the USA and the difficulty attracting and retaining both nursing faculty and hospital staff to this remote region. The Ugandan team also learned about some of the current modalities for teaching and optimizing student learning opportunities in the USA, such as simulation, and the shared difficulty in retaining nursing faculty in a competitive healthcare environment. Observations made both in the hospital and field contributed greatly in understanding the challenges the nursing school are facing, while also highlighting the success of the school to attract students and present a rigorous curriculum. Major challenges include finding qualified faculty to help with classroom teaching, how to transport students to other villages for exposure to remote HC II and III and how to educate students in a resource-poor environment where they will learn procedures didactically and in a skills laboratory that do not always have actual supplies available to perform assessments and procedures. Upon collaboration with the Ugandan team, several recommendations and possible solutions were discussed. Because of the great emphasis on remote clinic and rural outreach, the school has two community health courses and it was recommended that the Ugandan nursing students do clinical rotations with the VHTs. During VHT outreach, it is common for 20–50 villagers to congregate. Many have health issues that could be assessed while waiting for HIV testing and the other focused services the VHPs provide. Students will have ample opportunity to engage with villagers and perform assessments, physical exams, basic care, such as wound care, and to provide education grounded in public health principles and prevention. Recognition of more serious conditions can result in referral to the HC IV. Ultimately, as students graduate, an RN could be sent with the VHTs to provide a greater skills mix with the objective of providing more care in the villages, prescription of basic medications and performing minor procedures. The school is aligned with the HC IV community hospital, as well as all the VHTs, so the structure for students to accompany VHTs already exists but primary care objectives and competencies for this clinical experience need to be developed and is ongoing. To help alleviate the stress on the nursing director who is also teaching most of the classes, affiliate faculty status was offered by the US university and was accepted by the Ugandan director. In keeping with the counterpart concept model, the goal is to create a long-term collaboration between the two schools, with the initial objective being to provide foundational information
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and communications technology (ICT) support to the Ugandan director and faculty. A trial of collaboration between the US university and the Ugandan university will occur during the spring of 2015, with a focus on the community health clinical of the Ugandan students and the use of ICT with the goal of integrating Ugandan student classroom experiences with their clinical experiences. The Ugandan school decided to place students with the VHTs but was uncertain about how to create a rigorous clinical experience without resources. To address this, an Educational Wiki page was developed to post and share documents such as health assessment forms, online tutorials and teaching plans for the students to utilize. This page can be accessed by both US and Ugandan faculty. The Ugandan faculty can further decide to open it to their nursing students or to use the shared documents to create their own Wiki page for their students. It is important to note that there is often a misalignment between westernized ICT systems and those of the emerging world where poverty, illiteracy and poor infrastructure are major barriers to adoption of technology (Abbott & Coenen 2008). However, health communications with the use of ICT have been successful in many developing countries such as Kenya, Malawi, Rwanda and Haiti. The ease of use provided by platforms, such as Wiki, has increased the sharing of educational and medical resources around the world (Boulos et al. 2006). According to Boulos et al. (2006), a Wiki is a website that contains content that can be edited and used for obtaining and sharing knowledge, as well as engaging in collaborative engagement. They require minimal skill to establish and maintain, making them ideal for individuals of all educational levels. They are also extremely useful for clinicians in remote or rural areas that may be isolated. The use of a Wiki page to create a social and professional relationship can provide much needed support, as well as encourage active involvement with engaged learning. Thus, a Wiki page was chosen because of the ease of use and the ability of the Ugandan faculty to share this tool with students and with the objective of mentoring Ugandan faculty in the use of an information management system that is easy to access. In addition, a community health clinical syllabus was shared to give the Ugandan faculty ideas for their clinical experiences. The Ugandan school director will also be paired with a US faculty to be mentored and she will prepare a class for presentation to the US students. At the end of the spring semester, feedback from both the Ugandan and US teams will be solicited to determine the success of the initial collaboration and long-term objectives. Inherent to the success of this collaboration will be recruitment of US faculty to assist the Ugandan faculty over the next several semesters; this process has started and will be ongoing during the spring of 2015.
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Practical solutions to some of the supply issues noted in the clinical areas of the hospital were also made. Many items are purchased or donated without regard to actual need of the hospital and Ugandan staff were not always aware of alternative supplies and equipment that can be used. A list of high-need supplies and low-cost equipment items was generated in conjunction with hospital nursing administration to be reviewed so that appropriate changes in ordering can be made. Logistical items, such as storage and accessibility of supplies, were also addressed with recommendations resulting in changes beneficial to staff and students at both the hospital and in the nursing school skills laboratory.
issue that impacts populations that can be oceans apart. Thoughtful planning and systematic sharing and application of resources have the potential to assist schools of nursing in developing nations with implementation of current technology and practices. In addition, developing countries have a great desire to share their knowledge and application of disease management that Western health systems are not familiar with. Ultimately, intercollaborative sharing of information and resources between schools of nursing can have direct impact on global health initiatives and health care delivery by nurses in both HICs and LICs.
References Conclusions The new nursing school in southwest Uganda will provide education that aligns with the MDG and UMH goals, as well as with programmes already underway at the local HC IV community hospital. Currently, the school is affiliated with a major university and will utilize standardized Ugandan curriculum which will ensure graduates are prepared to address sexual and reproductive health, child health, health education, control and prevention of communicable diseases and identification of HIV/ AIDS, malaria and TB. School leadership is in place and has support from the Ugandan Nursing Council. This outreach addresses the school’s desire to further prepare the nursing school graduates to independently work and provide care in remote village clinics, as well as to possibly lead VHTs by providing an advanced nursing curriculum that is grounded in primary care principles. Curriculum development is being coordinated in a collaborative fashion with Ugandan leadership. Focus is on the specific needs of the Ugandan faculty and nursing students. Ultimately, the outcome of implementing a remotely focused and advanced nursing curriculum will benefit a huge region, the entire southwestern part of Uganda. In order to address the school’s vision to provide nurses trained in advanced techniques and primary care to this remote region, support from the VTT and affiliated universities will be formal and ongoing. Progress thus far is promising, with both the hospital and Ugandan school of nursing having a direct relationship with multiple supportive entities in the USA. Formal plans for ongoing support are in progress. Implications for health policy
Nurses in the developing world have great need and a desire to collaborate with Western universities and hospitals. They desire to be active in the development of foundational infrastructure and evidence-based practices that are both culturally relevant and practical for the difficult environments in which they practice. As the recent Ebola epidemic highlights, health is a global
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Abbott, P.A. & Coenen, A. (2008) Globalization and advances in information and communication technologies: the impact on nursing and health. Nursing Outlook, 56 (5), 238–248. Bender, D.E. & Pitkin, K. (1987) Bridging the gap: the village health worker as the cornerstone of the primary health care model. Social Sciences Medicine, 24 (6), 515–528. Boulos, M.N.K., Maramba, I. & Wheeler, S. (2006) Wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. BMC Medical Education, 6, 41. Decroo, T., et al. (2013) Community-based antiretroviral therapy programs can overcome barriers to retention of patients and decongest health services in sub-Saharan Africa: a systematic review. International Health, 5, 169–179. DeSantis, L. (1995) A model for counterparts in international nursing. International Journal of Nursing Studies, 12 (2), 198–209. Dick, J., Clarke, M., van Zyl, H. & Daniels, K. (2007) Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector. International Nursing Review, 54, 383–390. Dunlap, R.K. (2013) Nursing theory and the clinical gaze: discovery in teaching theory across a cultural divide. Nursing Science Quarterly, 26 (2), 176–180. George, E.K. & Meadows-Oliver, M. (2013) Searching for collaboration in international nursing partnerships: a literature review. International Nursing Review, 60, 31–36. Kellerman Foundation (2013). Providing Hope and Health in Uganda. Available at: http://www.kellermanfoundation.org (accessed 3 May 2014). Kemp, J. & Tindiweegi, J. (2001) Nurse education in Mbarara, Uganda. Journal of Advanced Nursing, 33 (1), 8–12. Lovett, W. & Gidman, J. (2011) Reflecting on the learning experiences of student nurses in rural Uganda. British Journal of Community Nursing, 16 (4), 191–195. Mackey, S., Hatcher, D., Happell, B. & Cleary, M. (2013) Primary health care as a philosophical and practical framework for nursing education: rhetoric or reality? Contemporary Nurse, 45 (1), 79–84. Nalwadda, C.K., et al. (2013) Community health workers – a resource for identification and referral of sick newborns in rural Uganda. Tropical Medicine and International Health, 18 (7), 898–906.
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Nguyen, L., et al. (2008) Intent to migrate among nursing students in Uganda: measures of the brain drain in the next generation of health professionals. Human Resources for Health, 6, 5. Palazuelos, D., et al. (2013) 5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting. Global Health Action, 6, 19658. Rockers, P.C., et al. (2012) Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment. BMC Health Services Research, 12, 212. Uganda Ministry of Health (2011). Uganda health system assessment 2011. Available at health.go.ug/docs/hsa.pdf (accessed 3 May 2014). Uganda Ministry of Health (2014). Health Sector Strategic Plan (HSSP) III, 2010/11–2014/15. Available at: http://www.health.go.ug/docs/HSSP_III _2010.pdf (accessed 3 May 2014). United Nations (2013). Overseas Development Institute Uganda Case Study for the MDG Gap Task Force Report. Available at: http://www.un.org/en/ Development/desa/policy/MDG_gap2010/mdggap_uganda_casestudy .pdf (accessed 3 May 2014).
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United Nations Population Fund (2011). Uganda Country Profile. Available at: http://www.unfpa.org/public/ (accessed 3 May 2014). van de Giessen, E. (2005). Peace Park Amid Violence? Institute for Environmental Security. Available at: http://www.envirosecurity.org/ (accessed 15 June 2014). World Health Organization (1978). Declaration of the Alma-Ata report from the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Available at: http://www.who.int/publications/ almaataDeclarationen.pdf?ua=1 (accessed 3 May 2014). World Health Organization (1984) Education and Training of Nurse Teachers and Managers with Special Regard to Primary Health Care. World Health Organization, Geneva. Available at: http://www.whqlibdoc .who.int/trs/WHO_TRS_708.pdf (accessed 3 May 2014). Ziegler, P.B., Anyango, H. & Ziegler, H.D. (1997) The need for leadership and management training for community nurses: results of a Ugandan district health nurse survey. Journal of Community Health Nursing, 14 (2), 119–130.
