Improving Nursing and Midwifery Education in a Resource-Limited Context: An Initial Evaluation

Nursing and Nurse-Midwifery Education in Liberia

As in much of Africa, Liberia is a challenging place in which to provide health care and higher education. Nursing and midwifery education is provided by both hospital-based schools and institutions of higher learning, culminating in a diploma or degree. After training, individuals must pass the national state board examinations to qualify as either RNs or registered midwives. The Liberian Board of Nurses and Midwifery (LBNM) regulates practice, education, examination, and registration of nurses and midwives in the country and works with the government to ensure accreditation of all programs (Flomo-Jones, 2013). In 2010, when the MSNEd program began, there were eight accredited schools of nursing/midwifery providing diploma and/or degree programs in Liberia, and four additional schools opened by the time the third cohort was admitted. The number of nurses with postgraduate education is low. The only postbaccalaureate nursing program in Liberia was a master's degree in nursing management program, which opened in 2004–2005 at Cuttington University and as of 2013 had graduated nine students (Flomo-Jones, 2013). The country currently has no PhD programs in nursing, and thus few doctorally prepared nurses. Although of high potential value, nursing research is almost nonexistent in Liberia and the use of evidence-based practices has been abysmally poor (Flomo-Jones, 2013).

Description of the MSNEd Program

To meet the need for qualified nurse educators to teach in Liberia's schools of nursing and midwifery, the first MSNEd program was opened in 2010, only the second master's degree program in nursing in the country. The MSNEd program was developed by expatriate nurse leaders in collaboration with the MOHSW, USAID, and MPCHS, where the program is held and administrated. The curriculum was modeled on the National League for Nursing (NLN) Core Competencies for Nurse Educators (NLN, 2005) and accredited by the Ministry of Education, Republic of Liberia. The first three cohorts of students were admitted September 2010, January 2012, and May 2013, respectively. Doctorally prepared faculty were recruited from nursing schools across the United States to teach in the program. In addition, master's-level nurse educators taught professional writing, advanced health assessment, and ethics, and a Liberian faculty member from Liberia Institute of Statistics and Geo-Information Services taught the statistics course.

Accredited schools of nursing and/or midwifery in Liberia were invited to send to two faculty candidates to the program. Admission requirements included an RN and/or registered midwife with current license; a baccalaureate degree in nursing, midwifery, or related field; two recommendation letters; and a successful entrance examination and interview. The initial cohort had an enrollment of 17 students; 15 were from the eight accredited Liberian schools of nursing in existence at the time. In addition, the Liberian Chief Nursing Officer from the MOHSW and a member of the LBNM were also admitted to the program. Cohorts two and three enrolled 16 students each, drawing from the original eight schools and from four newly opened schools and the LBNM. Funding for the first three cohorts of the MSNEd program was provided by the USAID/ForeCast and USAID/World Learning through MPCHS. Funding provided tuition, textbooks, laptops, airfare, and stipends for visiting faculty. Each sending school was asked to sign a memorandum of understanding (MOU) with each of their faculty members admitted to the program. In the MOU, the school agreed to provide half the faculty person's salary while in the program. In return, the candidate agreed to return to the sending school to teach for at least 2 years after graduation.

The MSNEd curriculum consists of 14 courses and one practicum, for a total 52 credits (41 theory credits and 11 practicum credits). The program encompasses three academic semesters, an intersession, and a summer session, over a period of 18 months. A teaching practicum constitutes the final semester of the program. For the practicum, students return to their home institutions to teach at least one three-credit course and to design and implement an in-service program for fellow faculty. Practicum students submit weekly reflection papers and reports to MSNEd faculty.

The purpose of this study was to evaluate program outcomes of the first three cohorts of the MSNEd program in Liberia. Specific aims were to (a) evaluate whether graduates met end-of-program outcomes, (b) evaluate graduate and employer (dean/director) satisfaction with the program, and (c) examine if and how the MSNEd program affected graduates' work, career advancement, and leadership development. An additional aim was to determine what, if any, role the graduates played during the 2014–2015 Ebola crisis in Liberia.

Participants and Design

Graduates of the first three cohorts (September 2010 through August 2012, January 2012 through August 2013, May 2013 through November 2015) of the MSNEd program (n = 43), and the deans/directors of associated nursing schools (n = 9), were invited to participate in this descriptive research study. (Graduation dates were determined by institute schedules and reflect delays between completion of program requirements and actual graduation of MSNEd students. The third cohort's education was disrupted due to the Ebola crisis, which postponed completion and graduation.) Quantitative and qualitative data were collected via electronic survey and responses summarized.

Study Questionnaires

Both quantitative and qualitative data were collected via two study questionnaires developed for this investigation: one for MSNEd program graduates, and one for deans/directors of the schools of nursing/midwifery that sent faculty as students to the program. Participants were asked to rate items on Likert scales and to provide written elaboration of their responses. Both questionnaires included sets of questions pertaining to end-of-program outcomes for graduates (Tables 1–2), asked participants to rate their overall satisfaction with the program, and provided an open-ended opportunity to provide any additional comments. The graduate questionnaire collected basic demographic and work information so as to describe the sample, asked graduates to rate their level of confidence as a nurse educator since graduating from the program, and asked graduates to indicate scholarly efforts since graduation. Graduates were also asked what, if any, role they played during the 2014–2015 Ebola crisis. On their questionnaire, deans/directors were asked to comment on any observed changes in the graduate's work as a result of the education received. They were also asked if each of the graduates from their school served their term at the school after graduation, as specified in MOU with the school.

Table 1: Graduates' Responses Regarding Achievement of Program Outcomes

Table 2: Deans' Responses Regarding Graduates' Achievement of Program Outcomes

Procedures

Approvals from institutional review boards in Monrovia, Liberia, and in Boston, Massachusetts, were obtained before initiation of the study. Contact information for all program graduates and for deans/directors of associated nursing/midwifery schools was obtained from the nursing program office at MPCHS. Data were collected via administration of electronic questionnaires using LimeSurvey^®, an open-source software tool used to conduct online surveys.

Graduates of the first three cohorts of the MSNEd program were invited to complete the graduates' questionnaire, and deans/directors of associated schools of nursing/midwifery were invited to complete the deans'/directors' questionnaire. Invitations containing a link to the relevant electronic study questionnaire were e-mailed to potential participants. The first questionnaire page described the study, including its voluntary nature. At the end of the first page, participants were instructed to press the “NEXT” button if they agreed to participate, thus indicating consent. After the questionnaire was opened, participants could stop and save answers and continue responding later at their convenience. The study was conducted over a period of approximately 4 months between late May 2017 and early September 2017. Given that some potential participants lived in areas without reliable or regular access to e-mail, the Liberia-based co-investigator (E.B.) made telephone calls to each prospective participant to alert them that an invitation had been sent via e-mail and to confirm the correct e-mail address. If preferred, a hard copy of the questionnaire was delivered to the participant. Reminder e-mail or telephone calls were made monthly to encourage response. A $5 prepaid cell phone credit was sent via text message to participants who completed the questionnaire. Descriptive statistics were used to describe the sample and to summarize results from quantitative survey questions. Qualitative data from the open-ended questions was extracted and copied into a Microsoft Word^® document. Responses to open-ended questions were sorted into lists (e.g., organizations where participants worked during the Ebola crisis) or common themes (e.g., regarding feedback about the MSNEd program). As appropriate, we counted the frequencies of specific responses in order to rank responses according to how often they occurred. Findings regarding content and frequency for each question were then summarized.

Description of Sample

Graduate Sample. The 43 living graduates from the first three cohorts were invited to participate. Thirty-three graduates (76.7%) completed the questionnaire (two by hard copy), of which 12 (36.36%) were male and 21 (63.67%) were female. The mean age of graduate participants was 45.16 years (SD = 9.53; range = 34 to 63 years). Twelve participants graduated in cohort 1, 11 in cohort 2, and 10 in cohort 3. The mean number of years of clinical practice prior to entering the MSNEd program was 11.41 years (SD = 8.41; range = 2 to 29 years), and mean for teaching experience was 4.12 years (SD = 3.51; range = 0.5 to 18 years). Most of the graduates (n = 25, 75.76%) were employed by a school of nursing or midwifery at the time of the study, with all but one of the remaining participants working in health care-related positions (e.g., World Health Organization, LBNM, MOHSW, and nongovernmental organizations).

Dean/Director Sample. Twelve schools of nursing/midwifery collectively sent 46 faculty to the MSN program in the first three cohorts (range = 1 to 7 faculty sent; an additional three students were sent by the MOHSW and LBNM). Of the sending schools, two had no graduates for evaluation (one sent one faculty member who did not graduate; the other had two graduates who both left the school prior to the current dean's arrival). For a third school, the dean was the only graduate of the MSNEd program; therefore, because she could not evaluate herself, the third school did not have any graduates to evaluate. Thus, deans/directors from nine schools were eligible to complete the deans/directors' questionnaire. All nine did so (one by hard copy), providing a 100% response rate for eligible deans/directors, representing eight of the 10 schools with graduates from the first three cohorts.

Of the 46 faculty sent by the schools, two did not complete the program, one died during the program, three died shortly following graduation, and one did not return to the sending school and thus could not be evaluated. Therefore, 39 graduates from the first three cohorts were faculty eligible for evaluation by deans/directors. Altogether, the deans/directors evaluated 33 of the 39 eligible graduates. Of the six graduates not evaluated by deans/directors, three were current deans and thus not able to evaluate themselves, two had no dean available to evaluate them, one did not return to the sending school and therefore was unable to be evaluated by the sending dean, and, in one case, the dean was able to evaluate only six of the school's seven graduates due to survey space limitations.

Outcomes

Did Graduates Meet End-of-Program Outcomes? To determine whether graduates achieved end-of-program outcomes, graduates were asked to rate themselves, and deans/directors were asked to rate their faculty graduates, on whether outcomes were met. Each outcome was rated on a Likert scale from 1 (never) to 5 (always). Mean scores for graduates' self-ratings ranged from 3.25 to 4.88; graduates perceived that they met the program outcomes sometimes for two outcomes, to very often or always for the remaining five outcomes (Table 1). Mean scores for deans/directors' ratings of graduates ranged from 3.90 to 4.45, indicating that overall, graduates met end of program outcomes very often or always (Table 2).

Did the MSN Program Affect Graduates' Work, Career Advancement, and Leadership? To address this aim, graduates were asked as series of questions. They were asked to rate “How much has your work or work behavior changed because of the education you received in the MSNEd program?” on a Likert scale ranging from 1 (no change) to 4 (a lot of change). Four graduates (12.12%) indicated some change the rest (n = 29; 87.8%) indicated a lot of change. On a Likert scale from 1 (strongly disagree) to 5 (strongly agree), all graduates indicated that they agreed (n = 8; 24.2%) or strongly agreed (n = 25; 75.78%) that they were more confident as a nurse educator since graduating from the MSNEd program. Graduates reported a high degree of professional engagement and activity since graduating from the program: for example, 64% worked or volunteered for the LBNM, and 45.5% worked or volunteered for another nursing, midwifery, or other organization (Table 3). They all reported that they had shared what they learned in the MSNEd program with others: 33 reported that they shared what they learned with other instructors or faculty, 32 with other professionals in a clinical setting, 31 with students, and 19 with people in the community. Twenty-six graduates (78.8%) reported that they had been promoted at work since graduating from the program. Positions held by graduates at the time of the study indicate high levels of responsibility and leadership at academic institutions, in clinical or public health service, and in professional organizations. In addition to instructor, professor, and lecturer positions, positions held included dean, associate dean, department chairperson, program head, curriculum specialist, project manager, program coordinator, supervisor, director (of nursing/midwifery services, health sciences, monitoring and evaluation), public health promotions officer, and chief nursing officer.

Table 3: Professional Activities Since Graduating From the Program

Deans/directors were asked questions to ascertain how the program affected graduates' work upon return to the sending school. Of the 46 faculty sent by schools to the MSN program, 43 graduated; one died while in the program, and two did not complete the program. Deans/directors reported that of the 43 graduates from their schools, 33 completed the MOU established with the sending school; three did not complete the MOU due to death shortly after graduation, and seven failed to complete the MOU. On a Likert scale ranging from 1 (no change) to 4 (a lot of change), deans/directors indicated that their returning graduates' work or work behavior changed because of the education they received at the MSNEd program a little (n = 4; 12.1%), some (n = 18; 54.5%), or a lot (n = 11; 33.3%). On a separate Likert scale ranging from 1 (not at all) to 4 (a lot), deans/directors indicated that their returning graduates used the skills and knowledge they gained from the MSNEd program a little (n = 5; 15.2%), some (n = 14; 42.4%), or a lot (n = 14; 42.4%).

Deans/directors responded to the open-ended questions, such as “What has changed as a result of the graduate's learning, and what impact has it had on your program?” Positive changes were noted in many areas, including curriculum review and development, test construction, lesson plan preparation, improvement of educational materials and other learning aids, planning and conducting teachers' workshop, engaging students more effectively, counseling students, assessing faculty teaching skills, developing and/or modifying documents used for student assessment, policy review and development, improving educational record keeping, and administrative responsibilities. Also noted were graduates' increased leadership responsibilities, mentoring faculty and staff, innovative teaching, and application of evidence-based practice in teaching and at clinical sites. However, not all aspects of changes in graduates' work/behavior were construed as positive. One dean commented that a graduate “became ambitious and challenged authority, wanted higher position and pay. This behavior made it difficult to work with her.” Another dean commented that his graduate “was mainly focused on power to change leadership in the school of nursing when there was no need for change.”

Satisfaction With the MSN Program. Satisfaction with the MSNEd program was rated on a Likert scale from 1 (not at all satisfied) to 5 (very satisfied). For graduates, 14 (42.4%) indicated they were satisfied and 19 (57.6%) indicated they were very satisfied with the program. Deans/directors reported being satisfied (n = 3; 33.33%) or very satisfied (n = 6; 66.67%) with the program.

Graduates' Role in Responding to the Ebola Crisis. We asked graduates what, if any, role they played in responding to the Ebola crisis. Open-ended responses indicated that all but one graduate played an active role in responding to the Ebola crisis. Participants worked for various organizations during the crisis, including the Liberian MOHSW, the Liberian Nurses Association, the International Rescue Committee, various clinics and hospitals, and various nongovernmental organizations, including Médecins Sans Frontières. Some provided direct clinical care, and several served in leadership roles (e.g., supervisor, manager, unit leader) in Ebola treatment units, primary health clinics, and hospitals. Many conducted trainings (several as master trainers) or served as consultants in infection prevention and control, educating health care providers and community members. They were involved with various training programs, such as leading “Keep Safe Keep Serving” trainings with nurses and other health care professionals. One graduate led a team to supply drugs and desperately needed infection prevention and control supplies to health facilities, two worked as psychosocial counselors at Ebola treatment units, and another helped relatives of Ebola victims by providing counseling and giving food and supplements. Much of the work the participants did was voluntary. As described by one participant:

I voluntarily trained community members how to prepare chlorine solution for hand washing and the proper use of it. I encouraged sick people to go to the hospitals for treatment and also advised my professional colleagues not to involve themselves in treating sick people at home.

Additional Feedback About the Program. Participants were given the opportunity to provide any additional comments, suggestions, or feedback regarding the program at the end of the questionnaires. Twenty-seven graduates and eight deans/directors provided comments. Graduates provided overwhelming positive remarks, seeing the program as highly beneficial for themselves, their profession, and their country. Several recommended that the program be opened to nurses who are not currently employed in the faculty role but who aspire to be nurse educators. They saw the current requirement that students be faculty sent by a school of nursing/midwifery as limiting and that opening the program to other qualified nurses would provide an important opportunity to increase—not just improve—the nurse educator workforce. A second recurrent recommendation concerned strengthening capacity and overall sustainability of the program with the goal that it eventually will be self-sustaining rather than relying on expatriate faculty. Several graduates expressed the need for MSNEd graduates to continue their education to achieve a PhD so that the program could eventually be fully taught by Liberian nurse faculty. Having graduates coteach in the program with experienced expatriate professors was also seen as a way to further strengthen self-sufficiency. A third frequently expressed recommendation concerned accountability of program graduates. There was concern regarding the need for graduates to fulfill their commitment with institutions that recommended them (e.g., to honor their MOU) and for schools to be able to retain their faculty. Accountability of graduates to implement what was learned in the program was also expressed. Additional recommendations included continuing education opportunities for graduates, that the LBNM use graduates for review and revision of nursing and midwifery curricula, and for graduates to get involved in research “as a way in which we can be able to make a greater impact in the nursing profession in Liberia.”

Comments from deans/directors were also positive, expressing a desire to see the program continue. As with several graduates, some deans emphasized the importance of graduates returning to their sending school, as stipulated in the MOU, and recommended a system be put in place to help ensure that graduates do so.