The Galápagos, an archipelago in the Pacific Ocean 600 miles off the coast of Ecuador, has a rapidly growing human population with complex health needs compounded by growing tourism. Ecuador is considered a middle-income country, yet the remoteness of the islands significantly limits access to many aspects of health care and is a barrier to recruit and retain a sufficient cadre of qualified health care professionals. One major barrier faced by nurses in the Galápagos is a lack of availability of current continuing professional development (CPD), particularly in their native Spanish language and appropriate for their unique island culture. Evidence has long linked availability of ongoing education as a strong attraction to recruit and retain personnel in remote areas (Sherwood, 1995). Collaborative partnerships have helped to address the CPD needs of health care personnel working in geographically remote, low-resource areas and improve retention. An emerging initiative, or convenio, between the Hospital Oskar Jandl on San Cristóbal Island, the Universidad San Francisco de Quito (USFQ), Ecuador's Ministerio de Salud de Pública, Ecuador, and the University of North Carolina School of Nursing (UNC SON) at a major public university in the southeast is focused on expanding access and quality of health care for the people of the Galápagos Islands. This article reviews the evidence on providing professional development from high-resource countries to low-resource countries/areas, describes the development and evaluation of a program targeting nurses on San Cristóbal Island in the Galápagos, and presents plans to sustain a culturally relevant international professional nursing development partnership.
The literature was reviewed to provide evidence that informed the development of programs that were provided in the UNC SON in this partnership. A limited number of reports were found on the topic of delivering educational programs to nurses or other health professionals from high- to low-resource countries or areas (Battat et al., 2016; Clark et al., 2015; Engel & Love, 2013; Gower, van den Akker, Jones, Dantas, & Duggan, 2016; Hosey, Kalula, & Voss, 2016; Kaddumukasa et al., 2014; Medina-Presentado, et al., 2017; Shimizu et al., 2014; Wewer Albrechtsen et al., 2017).
If reported at all, the number of participants was small, although skewed by a report of 29,469 enrolled in a massive open online course (Wewer Albrechtsen et al., 2017). Only three reports were exclusive to nurses (Clark et al., 2015; Collins, 2011; Hosey et al., 2016); another four included nurses but did not report specific numbers of nurses (Engel & Love, 2013; Medina-Presentado et al., 2017; Shimizu et al., 2014; Wewer Albrechtsen et al., 2017). The remaining studies primarily focused on physician education.
The United States was the most common high-resource country involved in developing programs to a diverse group of low-resource countries. Onsite educational interventions were provided in rural clinics and hospitals (Battat et al., 2016; Clark et al., 2015) or teaching hospitals or specialty centers or clinics (Collins, 2011; Engel & Love, 2013; Kaddumukasa et al., 2014). Other programs were delivered via the Internet (Hosey et al., 2016; Medina-Presentado, et al., 2017; Shimizu et al., 2014; Wewer Albrechtsen et al., 2017).
Programs were delivered using traditional in-person teaching methods (Clark et al., 2015; Engel & Love, 2013; Kaddumukasa et al., 2014) with intensive and long-term in-person interactive programs having the biggest impact on participants' outcomes in the long term (Hudspeth, Curry, Sacks, & Surena, 2015). Nevertheless, cost effectiveness of face-to-face CPD for health care professionals requires long-term commitment and institutional support to create and sustain changes in clinical practice (Clark et al., 2015; Engel & Love, 2013; Gower et al., 2016). Video presentations with synchronous attendance (Battat et al., 2016; Medina-Presentado et al., 2017) primarily have been used for physicians. Although the cost effectiveness and efficiency of providing Internet-based programs to providers in remote regions is indisputable, the lack of technological access makes it difficult to justify implementation in some settings (Collins, 2011; Hosey et al., 2016; Shimizu et al., 2014; Wewer Albrechtsen et al., 2017).
Cultural Relevance and Stakeholder Engagement
Engagement with local stakeholders is the foundation of collaborative partnerships between providers of CPD from higher resource nations working with lower resource communities of practice. Partnerships emerge from time spent listening and engaging local stakeholders in the educational needs' assessment and planning process (Clark et al., 2015). Establishing trust through open communication (best in the native language) will help develop culturally relevant programs delivered using appropriate teaching methods mindful of the local context and needs (Case, 2015; Clark et al., 2015). Involving a key local leader in the role of champion or cotrainer builds local support and helps assure sustainability of the program (Collins, 2011; Engel & Love, 2013; Gower et al., 2016). Program delivery must center on cultural responsiveness, native language, and respect and include a comprehensive evaluation framework to better explore meaningful change in practice and patient outcomes (Engel & Love, 2013; Gower et al., 2016).
Development and Implementation of a Continuing Professional Development Program
An outgrowth of a partnership that began in 2006 when UNC and USFQ initiated joint geological and biological research in the Galápagos ( https://Galapagos.unc.edu) led to a growing interest in developing health care quality in the Galápagos, and the UNC SON responded to an invitation for an assessment visit in January 2016. Administrators from the UNC schools of nursing and public health conducted a site visit and initial needs assessment at San Cristóbal's Hospital Oskar Jandl. Using findings from this report (Sherwood & Bentley, 2016), an intention was developed to include bilingual faculty and students in a collaborative partnership to provide educational development programs for the hospital nursing staff.
A three-person team, all fluent in Spanish, completed a second visit in summer 2016. Using a survey of stakeholders and interviews with nurses from Hospital Oskar Jandl, the team completed a community assessment of health care needs. The assessment confirmed the need for professional skills training, continuing nursing education, and interdisciplinary engagement for nurses to coordinate safe quality care (Bentley et al., 2016). Subsequent visits in 2017 by nursing faculty refined assessment data with Hospital Oskar Jandl's nursing staff, community members, and director of nursing (Harlan, July 15, 2017, personal communication), setting the stage for the first continuing education engagement. The professional development activities were deemed nonhuman subjects research by the corresponding author's institution.
San Cristóbal is one of the four habitable islands in the Galapagos. For many years the primary source of health care was a small underresourced hospital with fewer than 20 beds. Most nativos traveled to mainland Ecuador to seek health care, in particular specialty care. To overcome the need for this rigorous and costly travel, the 24-bed Hospital Oskar Jandl replaced the aging facility, opening in December 2014 (Ministerio de Salud Pública, 2015). The hospital benefits 7,500 island residents, 26,800 inhabitants of the archipelago, and thousands of tourists. The hospital also has access to one ambulance airplane and two ambulance helicopters to transport patients to mainland Ecuador if more specialized services are required (Ministerio de Salud Pública, 2015). The hospital has approximately 24 RNs, 10 specialist physicians, and 18 medical residents as licensed care providers (Maria Francisca Murgueitio Fuentes, November 15, 2017, personal communication).
The partnership agreed on a plan for two bilingual graduate students, also experts in a relevant clinical area, to provide professional development for the nursing staff at the hospital on San Cristóbal Island supervised by faculty with prior experience in the Galápagos. Nurses had expressed the need to learn more about the new science for safety and quality as required by their pending application for hospital accreditation; therefore, the key feature for this visit was to assist the nurses in understanding and integrating the quality and safety competencies from the internationally recognized Quality and Safety Education for Nurses project (Cronenwett et al., 2007). The primary education session had 32 attendees who were provided with Spanish language translations of the competencies and tools. Concurrent with the visit, the Ministry of Public Health was scheduled to visit the hospital to promote a nationwide breastfeeding campaign (Ministerio de Salud Pública del Educador Coordinación Nacional de Nutrición, 2011) and perform a review of hospital readiness. A just-in-time program on prevention and management of common breastfeeding problems was delivered twice in partnership with one of the hospital nurses who was familiar with the campaign standards.
The two graduate nursing students spent time with the local nurses and hospital leadership in their daily work to better understand the cultural context, barriers, and challenges faced on a daily basis and to determine future education topics. During these rounds, the two visitors also shared more informal updates on communication, security, orientation for newly arrived nurses, and up-to-date evidence-based resources. Although no formal evaluation was undertaken, relationships were strengthened, and anecdotal reports informed the program that was delivered the next summer.
In summer 2018, two different graduate family nurse practitioner students presented two topics. Didactic content was presented the first week with hands-on low-technology simulation skills training conducted the second week. The first topic was advanced cardiac rescue based on skills and principles of the American Heart Association's Advanced Cardiac Life Support certification program, using the same text (in Spanish) and modifying scenarios and resources to what was available at the site. A strong focus of the advanced cardiac rescue was on teamwork and communication. The second topic was evidence-based principles of wound care.
Twenty-seven individuals attended the cardiac rescue sessions and 24 attended the wound care sessions. Nurses, physicians, a nurse anesthetist, and an ambulance driver participated. The average length of experience was 6 years (range = 1 to 32 years). In preprogram assessment, less than half (46%) reported having performed advanced cardiac rescue in the hospital setting and although 75% reported providing wound care more than once per week, only 42% felt comfortable with educating patients about wound care. Tables 1–2 provide educational outcomes.
Knowledge and Perceived Comfort Before and After Advanced Cardiac Rescue Program
Knowledge and Perceived Comfort Before and After Wound Care Program
Participants thought that the sessions (advanced cardiac rescue, wound care) would have a profound effect on their practice (96%, 88%) and help them to develop new knowledge and skills (65%, 33%), review and maintain their knowledge and skills (23%, 42%), and meet patient needs (7%, 21%). Anecdotally, it was reported to the students that a few days after the training, the emergency department staff was observed putting into action their new skills and communication techniques with a critically injured patient. They expressed pride in their improved delivery of advanced cardiac rescue based on what they had learned during the training sessions and simulation activities.
For future endeavors, additional information was collected on technology and Internet availability and dependability. Although 63% of participants reported access to a computer, smartphone (46%), or cellular phone (58%), Internet dependability was lower; only 42% of the participants indicated the Internet was usually reliable at work, and only slightly more (51%) indicated it as usually reliable at home.
Recommendations for Future Collaborative CPD Partnerships
Face-to-Face Education and Training
Evidence supports face-to-face delivery of education as having a number of advantages, as well as challenges. This method requires periodic travel for experts to provide instructional presentations, hands-on training, and patient scenario simulations. Having in-person communication promotes rapport with all participants and reduces confusion (Clark et al., 2015; Engel & Love, 2013; Kaddumukasa et al., 2014). Cost considerations and time commitments are the primary concerns. Other considerations are language and preparedness in cultural sensitivity to fit the local context and stakeholder needs.
Train the Trainer
Often, geographically remote areas have invested in one or more of their own health professionals to travel and work directly with experts in a particular area. Through direct mentorship and coaching, these staff develop skills and knowledge to be able to then return to their home country to present what they have learned and assist others in development (e.g., train the trainer).
Traveling to visit experts has the advantage of observation of practices that can be applied at home, yet when experts travel to the local setting, they are able to better assess trainees in their home context. In particular, despite the lack of evidence reported in the literature on patient simulation provided to low-resource countries by outside agents, this was the request made most often by the Hospital Oskar Jandl staff at all levels. International development can follow the evidence supporting this approach in the United States to develop a variety of nursing skills (Lane & Mitchell, 2013; Shin, Park, & Kim, 2015).
As technology resources continue to expand globally, more education is being delivered in a variety of electronic formats. Electronic delivery may be outstripping traditional in-person delivery as the most frequent approach of most international CPD developed for health care workers between high-resourced and low-resourced areas (Collins, 2011; Shimizu et al., 2014; Wewer Albrechtsen et al., 2017). The same benefits apply in remote settings: staff have the opportunity to view asynchronous offerings on their own schedule or in a group setting. Voice-overs by a native speaker of the lower resourced area may also alleviate some feelings of foreign intrusion into their work lives and be more understandable. Costs vary widely depending on methods applied but may be more cost effective in the end. Selecting the type of technology with regard to functionality and practicality is the primary concern to ensure reliable delivery between settings, including matching delivery platforms and Internet bandwidth.
Many partnerships have integrated the three approaches with successful outcomes. Sherwood and Oppewal (2015) applied this strategy successfully in training interprofessional educators in Kenya by first leading a face-to-face workshop, developing a step-by-step train-the-trainer manual for participants, conducting biweekly teleconferences between the partners, and using an electronic platform for sharing educational resources.
Cultural and Contextual Barriers
Developing international partnerships is complicated because of language, cultural, and institutional differences. Electronic and/or face-to-face meetings can help assess readiness from all stakeholders and consider appropriate interventions that will yield participation and behavioral outcomes. Conversation needs to include program participants, as well as key leaders, to explain the concepts more thoroughly and to gain buy-in. The strategies or approaches used will depend on circumstances of each partnership to determine which approach or combination of approaches is the most viable option for all stakeholders.
It is vital to evaluate each iteration of programs delivered. In addition to learning outcomes, information could be collected in the future on the program itself, relevance to the participants' needs, cultural sensitivity, user friendliness, or other concerns. More robust outcome measurements may assess subsequent changes in health care delivery and patient health outcomes consistent with the Kirkpatrick program evaluation model (Kirkpatrick & Kirkpatrick, 2007). Other informative measurements and actions may include observations of actual change in nursing practice to improve safety and quality, such as new written protocols for nurses, new documentation expectations, independently developed programs including yearly skills practice or competency assessment, and tracked patient outcome data on benchmarks such as pain management scores or infection rates.
This emerging international collaborative partnership is built on assisting the nativos and the shared responsibility of developing the first official CPD and education partnership for nurses working in the Galápagos to ultimately improve health care for nativos. As the partnership continues to deepen, the basic components for successful education interventions and improvement strategies can be put in place to proceed with a plan that incorporates all three approaches described above—for example, tele-education with face-to-face patient scenario simulation. Despite challenges, with commitment and consideration, an evidence-based approach will ensure a successful partnership between the UNC SON, USFQ, and Hospital Oskar Jandl to develop a multimodal approach CPD program for nurses in the Galápagos and provide a model for other remote locations around the world.
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Knowledge and Perceived Comfort Before and After Advanced Cardiac Rescue Program
|Question||Before PD, % Correct||After PD, % Correct||% Improvement|
|What is the most important component of cardiac rescue?||50||84.6||34.6|
|What is the correct rate of chest compressions per minute?||65.4||96.2||30.8|
|What is the rate of compressions to ventilations for an adult?||73.1||92.3||19.2|
|What is the rate of compressions to ventilations for an infant with two rescuers?||80.8||88.5||7.7|
|Sure or very sure about performing||38||64||26|
|Increased comfort with advanced cardiac rescue||–||96a||–|
Knowledge and Perceived Comfort Before and After Wound Care Program
|Question||Before PD, % Correct||After PD, % Correct||% Improvement|
|What is the first step before doing any kind of wound care?||75||91.7||16.7|
|In general, wounds heal better in what type of environment?||12.5||79.2||66.7|
|What is the role of antibiotics in wound healing?||29.2||66.7||37.5|
|Comfort with patient teaching||42||95||53|