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Supporting Nursing Education and Professional Practice: Lessons from a
Decade of Work in India
Susan Dahinten, RN, PhD & Tarnia
Taverner, RN, PhD
UBC School of Nursing and
Brittany Watson, RN, MSNProvidence Health Care
Healthcare Education and Research Rounds, July 23, 2015
The University has a responsibility to educate students with internationally grounded perspectives and critical capacities
International development ‐ an important activity of the university
Why engage internationally?
Global health and international engagement are consistent with:
o
Florence Nightingale’s legacy of social action and service to those in need, locally and globally;
o
CNA position statement on Global Health and Equity (CNA, 2009): “nurses have the right and
responsibility to be cognizant and raise awareness of the root causes of inequity in global health and to
participate in finding solutions” (p. 1).
Why engage internationally?
The organization and regulation of nursing education and practice in India
History of engagement in Punjab, India
Building capacity in nursing education
Building capacity in nursing practice
o
The staff nurse role
o
Professional development needs of nursing staff
o
Academic‐practice partnership to support professional practice
Challenges and impact of engagements in India
Agenda
Indian Nursing CouncilNursing education:
Baccalaureate nursing degree (BScN, 4 years)General Nursing and Midwifery diploma (GNM, 3 years)Auxiliary Nurse & Midwife (ANM, 2 years)
Nurse registration:Indian Nursing Council → state nursing councilUntil recently: lifetime registrationCurrently: 5 year registration with continuing education requirements
The Organization and Regulation Of NursingEducation and Practice In India
National curricula
India has greatly increased its capacity for nursing education but still faces an acute shortage of nurses.
Rapid ↑ in educational capacity → questions about the quality of nurse education in many schools & colleges of nursing.
Requirements for nursing education: qualified nurse educators, a curriculum that is responsive to the country’s health care needs, and appropriate opportunities for clinical practice.
A 2011 Lancet article described nursing education in India as being “in crisis” and proposed improving educational capacity through nursing faculty development (Rao et al.)
Nursing Education in India
1998 –
2007
Partnership with Guru Nanak Mission Medical and Educational Trust (Dhahan‐Kaleran, Punjab)
2011 – present
Partnership with Baba Farid University of Health Sciences (Faridkot, Punjab)
School‐level partnerships
Overview of Engagements in India
Punjab: Population: 28 millionEconomically prosperousSocial indices -
mixed
(2) Baba Farid
University of
Health Services
(1) Guru Nanak College of Nursing
(Dhahan-Kaleran)
Capacity Buildingin Nursing Education
Partnership with Guru Nanak MissionMedical & Educational Trust
Partnership from 1998 –
2007:
Invitation to partner was facilitated by Canada‐India Education Society (CIES)
Primary Aim:To enhance baccalaureatenursing education at theGuru Nanak College ofNursing (GNCON)The 3rd BScN program in Punjab
1. Annual faculty exchanges
•
Focus: Faculty development
2. Bilateral Student Exchanges
3. Provision of learning resources
4. Also provided support for a 4‐year CIDA funded,
rural Primary Health Care Project (sponsored by CIES and Guru Nanak Mission Medical and
Education Trust)
Partnership Activities with GNCON
Helped to increase the profile and status of nursing as a profession
High success rate on state level nursing exams
Increased pool of BSN prepared staff nurses and educators in Punjab state
Faculty positions at GNCON are filled, MSc prepared faculty
The faculty are vibrant, confident and assertive
Impact of the Partnership with GNCON
Student Exchanges to/from GNCON
•
UBC students: observational and clinical experiences in acute care and community
•
GNCON students: attended classes, observational visits to
clinical sites, consulted SoN faculty re: research projects “My biggest
personal challenge
was understanding,
and then coming to
terms with, the
realities of limited
resources.”
Invited to partner in 2011
BFUHS oversees all health science programs in the state
560 bed university hospital
Nursing programs in Punjab
~ 100 colleges: BSc Nursing, > 95 opened since 2001
~ 35 colleges: MSc Nursing
1 PhD program (2012)
Partnership with Baba Farid Universityof Health Sciences,
College of Nursing
•
To provide for an exchange of educational and research opportunities to build academic capacity bilaterally:
Enhance the professional development of nurse educators at BFUHS in classroom & clinical teaching, and research (and leadership).Strengthen graduate nursing education at BFUHS.Advance scholarship in nursing.
To assist in addressing the education‐practice gap at the university hospital (enhance professional practice)
To increase global learning opportunities for graduate students from UBC SON and BFUHS UCON.
Objectives of the Partnership
Capacity building with MScN students through:
o
Guest lectures and workshops
o
Mentoring of thesis research projects
o
UBC‐BFUHS student research collaboration
o
Challenges: national curriculum and involvement of busy BFUHS faculty
To enhance the professional development of nurse educators at BFUHS through faculty exchange visits
To advance scholarship through inter‐university faculty collaboration in nursing research
Strategies for Capacity Building
•
Increased research capacity among BFUHS graduate students:
o
More relevant research questionso
Increased diversity in methodso
Increased rigour
•
Changes in the culture of nursing at BFUHS among graduate students
•
Greater engagement of BFUHS nursing faculty in research and publishing
•
Two collaborative research studies by faculty
•
UBC graduate student research in India
Impact of Capacity Buildingin Nursing Education
Capacity Building in Nursing Practice
Strategies
•To develop a better understanding of nurses’
roles and responsibilities, and the education needs of staff nurses
•To facilitate a system of continuing education for staff nurses at GGSH through an academic‐practice
partnership
Study #1: The Role of the Staff Nurse in Guru Gobind Singh Hospital in Punjab, India
T. Taverner1., H. C. Rawat2,. H. Kaur2,. B. Watson1,. L. Currie1,. V. S. Dahinten1
Institutional Affiliations:1
UBC School of Nursing
2
Baba Farid University of Health Sciences College of Nursing, Faridkot, Punjab, India.
To investigate the role and responsibilities of staff nurses at Guru Gobind Singh Hospital in Faridkot,
Punjab, India.
Study Purpose
Design: qualitative interpretative‐description
Target sample: healthcare providers who worked at GSSH & chose to participate in an interview conducted in English.
Data collection methods: focus‐group interviews were semi‐structured, using initial guide questions as prompts.
Focus group interviews were carried out by two experienced researchers in a room in the GSSH site, during a faculty visit from Canada to India.
Six focus groups were held over a 2 week period in April 2014; these were recorded and transcribed verbatim.
Methods
•
Each focus group had between 3 and 5 participants.
•
17 participants in total: 11 nurses and 6 physicians
•
The majority of the nurse participants were bachelor degree prepared (8 of the 11)
•
The number of years of work experience ranged from 9 months to 12 years for the nurses, and from 1
to 6 years for the physicians.
•
All the nurses were female, and 2 of the six physicians were female.
Study Sample
Study Findings: Codes and Themes
2 THEMES
Advanced Nursing Practice Partners in Care24 Codes
Autonomy Mutual RespectResponse SupportNeeds Must EducatorLife or Death Team workFreedom to Practice PreparationComfortable at ease PrideRole limitation Mutually BeneficialFirst responder RespectShock management & Preserving life Family Focused CareAdvanced practice Thinking ahead/ForecastingEducatorNurse Initiated CareReactive Care24/7 Care Provision
Many of the participants described the role of the staff nurse as an advanced practice nurse.
“We also care of emergency, we do CPR and according to need we use the defibrillator”.
Advanced Staff Nurse Role
Much of the practice was undertaken as a response to an emergency situation, with the sole aim of preserving life.
SN
“Because ultimately we have one goal to save the child henna (ok) so that’s why we perform independently these
things”.
Dr
“Like if the patient is dying at the spot and we take some time to come it’s only the staff nurse that is going to
resuscitate the patient at the spot. Most doctors may, late for some time, and its only staff nurse that is going to
intubate, sometimes we train staff nurse like this, they can intubate the patient at the spot”.
Advanced Staff Nurse Role
An aspect of their advanced practise was also to provide assistance and training to others with
advanced practice requiring specific skills.
“In nursery, just in nursery, like there is too little babies, there is difficulty to insert cannulas in new
born babies, we all nurses do it very well, but the Post Grads (newly qualified Drs) not, and we will guide”.
Advanced Staff Nurse Role
Throughout the data the excellent and mutually beneficial relationship between Nurse and Dr’s was
apparent.
“We are working as a team, not individually as a nurse or Dr”.
“The Staff nurses are helping us, how to intubate. Nurses are helpful for the practical knowledge for the newly,
new comers, for the students, or the newly Dr’s”.
“The Dr’s behave good with us and like they also teach us”.
Partners in Care
It was clear from the data that the nurses and Dr’s had a great respect and understanding of each
others professions.
“Dr alone can’t do anything in hospital, nurse alone can’t do anything in the hospital. Everyman is
needed, so it’s a teamwork”.
Partners in Care
In summary, the staff nurses’
role was enacted at an advanced level, the mutual respect between
physicians and staff nurses was apparent and their exemplary team work ensured patients received
care as and when required. While they described carrying out work according to task orientated care,
they also demonstrated and gave many examples of care which was informed by their excellent and high level critical thinking skills.
Conclusion
Study #2: The Continuing Education Needs of Nurses Working in Hospital
Environments in Rural Punjab, India
B. Watson, T. Taverner, V. S. Dahinten, & L. Currie,
Institutional Affiliation:School of Nursing, University of British Columbia
To investigate the continuing education needs of nurses working in hospital environments in rural areas of Punjab, India.
Study Purpose
Study Findings: Themes & Subthemes
Task‐driven Unpreparedness Learning Sideways
Nurse as task manager Physician as nurse educator Life‐long learning
Scope of practice Staff nurse fear Nurse led education
Basic education Staff nurse requests Assessment driven action
Unidentified critical thinking
“Task” is understood as work nurses complete to ensure patient care requirements are attended to either directly or indirectly. Tasks require independent nursing judgment and knowledge, based on nursing expertise, to ensure patient care decisions are adapted to the individual patient and the context of the clinical environment (Glazer, 2000).
Similar conceptualization of nurses’ roles amongst physicians and nurse participants suggests that nursing education may shape nurses’ perceptions of their role by emphasizing the importance of task completion.
Task Driven
“Sometimes when patient condition is very serious, and nobody it’s not possible [is available], the doctor’s not
there. Sometimes if any conditions happen then we will fear to how to handle … If doctor’s not here, then we will
face problems.”
“Sister nurse that you have met yesterday, she will teach mostly us things, but we need education, we don’t know the rationale behind it [tasks].”
Unpreparedness
“So I don’t think so I am well prepared for whatever I am doing, because side by side, everyday, whenever I come to the duty I learn new things. So I am learning sideways”.
“During BSc we will just learn NG, NG during degree time. Intubation is done after this period”.
Learning Sideways
The results identify nurses’ desire for continuing education and specific education needs. Nurses’capacity for higher‐level thinking is observed throughout the findings, through nurses’ critical thinking and advanced scope of practice. Nurses’requests for continuing education needs to be met to affirm nurses’ value, support their professional development and promote advancement of the nursing profession in India.
Conclusion
•
Enhance and develop formalized staff nurse education within the hospital.
•
Develop specialist education for areas such as critical care, emergency room care, neonatal care.
•
Develop specialist nurse roles to support advanced nursing practice.
Recommendations
Capacity Buildingin Nursing Practice
o
Academic‐practice partnership to support professional practice
Objectives
•
To establish a demonstration unit for excellence in nursing practice at GGSH.
•
Continuing education for staff nurses will be provided by visiting SON faculty and clinical nurse
specialists (adjunct faculty), and by BF UCON faculty.
•
3‐way academic‐practice partnership
•
To provide clinical educational experiences for graduate student and faculty visitors to UBC by matching visitors with clinical nurse specialists in
practice.
Continuing Education for Nurses in Practice
Impact: Sometimes the Unexpected
Through formal interventions
Informal – our visits ARE an intervention
May be a limited understanding of the potential of international partnerships (on both sides)
Participatory approach to needs assessment and strategic planning ‐may be unfamiliar and/or uncomfortable
Cultural challengesRelationship buildingCultural orientations to written vs oral communication
Different concepts and assumptions of good leadership
Geographic, time requirements, technology complications
Challenges of Engaging In International Partnerships
1.
Partnerships are for the long term.
2.
Partnerships need a clear focus from the beginning.
Objectives and expected benefits should be articulated and shared (internally and across institutions)
Set out clear expectations and assign responsibilities for each partner
Operate with written agreements
Lessons Learned
3. Have realistic objectivesThat match available resources
4. Resource issuesCommit internal funding to the partnership
Openly address problems of inequality of resources between partners
Lessons Learned
5.
Leadership and management of the partnership
High‐level champion
Strong and dependable leader – operations management (with dedicated time)
Important to understand the other institution’s approach to managing the partnership, and each other’s approach to leadership
Lessons Learned
6.
Maintaining the partnership
Meaningful participation in planning & decision‐making
Be prepared to address potential challenges, differences of perspective, and areas of disagreement directly and promptly
Regular communication – have mutually agreed standards, and recognize challenges to these standards
Avoid AssumptionsAsk questionsChallenge your own assumptionsDon’t assume you are understood
Lessons Learned
7.
The importance of personal relationships.
Lessons Learned
UBC faculty and studentsDevelop greater global awareness and cultural sensitivity, including understanding the influence of culture on nursing practiceConduct internationally‐based researchCanadaUBC educated nurses develop a better understanding of how to address the health needs of the Punjabi population in CanadaMany nurses educated in Punjab have immigrated to Canada and are able to practice as registered nurses in Canada after a bridging program that orients them to the Canadian health care system.
Benefits of International Engagementsto UBC & Canada
International partnerships are one strategy for building nurse education, research, and leadership capacity in
India, with the ultimate goal of enhancing the number and effectiveness of health human resources.
•Positive outcomes
•But the potential is also limited in the face of structural obstacles.
Recommendation: That international partnerships be supplemented with local support.
In Conclusion
