Journal of Nursing Education

Major Article 

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

Janice H. Goodman, PhD, PMHCNS-BC, PMHNP-BC; Edwin Beyan, MSNEd, RN; Edna Johnson, PhD, FNP

Abstract

Background:

This descriptive survey study provides the first evaluation of an innovative Master of Science in Nursing Education (MSNEd) program developed to meet the need for qualified nurse educators to teach in Liberia's schools of nursing and midwifery.

Method:

Quantitative and qualitative data were collected via electronic survey from MSNEd graduates (n = 46) and deans/directors of affiliated schools of nursing/midwifery in Liberia (n = 9) regarding end-of-program outcomes, graduate and employer satisfaction with the program, and how the program affected graduates' work, career advancement, and leadership development.

Results:

End-of-program outcomes are being met, and graduates and deans/directors both are highly satisfied with the program. Most graduates have been promoted and have assumed leadership positions in nursing and academia.

Conclusion:

The MSNEd program has enhanced the teaching and leadership capabilities of nursing and midwifery faculty throughout Liberia, providing a model for other countries needing to scale up the nursing workforce. [J Nurs Educ. 2018;57(12):712–719.]

Abstract

Background:

This descriptive survey study provides the first evaluation of an innovative Master of Science in Nursing Education (MSNEd) program developed to meet the need for qualified nurse educators to teach in Liberia's schools of nursing and midwifery.

Method:

Quantitative and qualitative data were collected via electronic survey from MSNEd graduates (n = 46) and deans/directors of affiliated schools of nursing/midwifery in Liberia (n = 9) regarding end-of-program outcomes, graduate and employer satisfaction with the program, and how the program affected graduates' work, career advancement, and leadership development.

Results:

End-of-program outcomes are being met, and graduates and deans/directors both are highly satisfied with the program. Most graduates have been promoted and have assumed leadership positions in nursing and academia.

Conclusion:

The MSNEd program has enhanced the teaching and leadership capabilities of nursing and midwifery faculty throughout Liberia, providing a model for other countries needing to scale up the nursing workforce. [J Nurs Educ. 2018;57(12):712–719.]

Nurses comprise 80% of the world's health care work-force (Benton, Pérez-Raya, González-Jurado, & Rodríguez-López, 2015). Particularly in resource-limited contexts such as sub-Saharan Africa, nurses and midwives often serve as the primary or only frontline health care providers. A strong nursing workforce is key to meeting individual, community, and global health goals. One of the most common ways to strengthen and empower nurses is through access to education and knowledge (Krubiner, Salmon, Synowiec, & Lagomarsino, 2016). A key way to accomplish this is to reform nursing education, including the preparation of nurse educators; however, a review of nursing education in 23 African countries found that only seven schools prepared nurse educators, and only five at the master's level (Klopper, Uys, & Sigma Theta Tau International, 2013). To meet the need for qualified nurse educators to teach in Liberia's schools of nursing and midwifery, a Master of Science in Nursing Education (MSNEd) program was developed in 2010. This article describes and provides the first evaluation of this innovative educational program.

Background

Liberia, located on the western coast of Africa, is one of the poorest countries in the world. Fourteen years of civil war (1989–2003) devastated its already fragile health care delivery system (Boozary, Farmer, & Jha, 2014). Medical and nursing/midwifery training suffered due to the absence of health care education during the war years and the loss of many professionals who fled the country (Congor, 2015; Varpilah et al., 2011). In 2006, there were fewer than 20 physicians amid a population of 3.38 million people. Nurses made up most of the health care workforce, with 668 nurses (RNs and licensed practical nurses) and 297 certified midwives, assisted by 1,091 nurses aides to provide the majority of primary health care (Varpilah et al., 2011). The country was faced with an acute need for increased numbers of qualified health professionals. Nevertheless, a 2007 survey conducted by the United States Agency for International Development (USAID, 2009) and Liberia's Ministry of Health and Social Welfare (MOHSW) found that only two schools of nursing had the appropriate resources (e.g., textbooks, teaching laboratories, demonstration models) to provide a conducive learning experience (Varpilah et al., 2011). Due to war, faculty did not have opportunities for continuing education and therefore lacked current information and experience with current teaching methodologies. Faculty development was identified as a priority in the 2007 USAID survey: there was a clear need for well-qualified faculty to teach in nursing/midwifery programs using instructional strategies to prepare students to meet international standards (Congor, 2015).

Significant work has gone into rebuilding Liberia's health care delivery system following the civil war. The creation of an Emergency Human Resources Plan by the MOHSW in 2007 led to the opening of new nurse/midwifery schools and expansion of existing programs, significantly increasing the numbers of nurses and midwives (Varpilah et al., 2011). It was in this context in 2010 that an innovative MSNEd program was developed and opened at Mother Patern College of Health Sciences (MPCHS) in Monrovia, the capital of Liberia. Faculty from nursing/midwifery schools from around the country participated in the 18-month program aimed at strengthening nurse educators' knowledge and skill. The idea was that more qualified nursing faculty would improve the quality of nursing education, which would, in turn, lead to better educated nurses and eventually to better care for patients throughout the country.

In early 2014, the Ebola crisis hit Liberia. The public health system infrastructure lacked the essential elements required to control the outbreak, including a strong health care workforce (Shoman, Karafillakis, & Rawaf, 2017). Health care workers caring for patients with Ebola were among those hardest hit. In Liberia, over 8% of its doctors, nurses, and midwives died from Ebola (Evans, Goldstein, & Popova, 2015), further decreasing the availability of health care workers and further worsening an already weak health system. The third cohort of MSNEd students were in the midst of their studies when, along with most schools in Liberia, the nursing school and MSNEd program closed due to health and safety concerns.

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.

Method

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 12), 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.

Graduates' Responses Regarding Achievement of Program Outcomesa

Table 1:

Graduates' Responses Regarding Achievement of Program Outcomes

Deans' Responses Regarding Graduates' Achievement of Program Outcomesa

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.

Results

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.

Professional Activities Since Graduating From the Program

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.

Discussion

Since its establishment in 2010, the MSNEd program at MPCHS has graduated 46 nurse educators. This initial program evaluation indicates that end-of-program outcomes are being met and that both graduates and the deans/directors of the sending schools are highly satisfied with program. By ensuring that graduates meet NLN nurse educator competencies, the program brings nursing education in Liberia to internationally referenced standards. This is key to enhancing the quality of the nursing workforce at national and international levels. Additionally, the MSNEd program has been successful in enhancing the career advancement and leadership development of its graduates. Overall, graduates reported that the program had shaped them to become effective in their roles in teaching and leadership within their institutions and in leadership roles in local, regional, and national arenas. Most (78%) have been promoted and have already assumed leadership positions in academic, professional, and government settings related to nursing and health. Graduates reported a high level of involvement in professional activities since graduating from the program. These findings suggest the substantial influence the graduates have and will likely have on nursing and midwifery in Liberia, underscoring the importance of the education they received.

Mentors have long played an important role in the career development of nurses (Riley & Beal, 2013). Although mentoring of students and other faculty was frequently mentioned, apart from co-teaching with expatriate faculty, there was no mention by graduates of being mentored themselves. This may be largely because these graduates are at the top of their profession in Liberia and thus may lack available and appropriate mentors locally. This may change as graduates from earlier cohorts begin to mentor newer cohorts of students and graduates; however, to more fully realize the potential of this program, it may be beneficial to intentionally establish mentoring programs for students, graduates, and other nursing faculty. Mentors could be program graduates or nursing faculty from other countries with an interest in global health and academic and leadership development.

Both graduates and deans/directors rated graduates' engagement in scholarship lowest of the seven program outcomes. Nevertheless, most graduates indicated that they had given formal didactic presentations to professional groups and presented at local, regional, national, or international meetings, and two graduates reported being an author on a peer-reviewed publication. Sharing nursing knowledge through scholarly publications and presentations is important to advance nursing/midwifery locally, nationally, and globally. Increasing skill development in scholarly writing and presentation is an area for continued development. Although nursing research is greatly needed to build a strong, localized, culturally relevant evidence base for nursing practice (Sun et al., 2015), nursing research is almost nonexistent in Liberia (Flomo-Jones, 2013). A surprising 42% (n = 14) of MSNEd graduates reported they had initiated or collaborated on a research study. What role they played or whether these studies were completed, still in progress, or otherwise, is not known; nevertheless, this is a promising finding given the clear need to build nursing and midwifery research capacity. Several graduates expressed their desire to be involved in research as a means to advance their profession and improve nursing care. The MSNEd program provided most students with their first exposure to research and evidence-based practice and may have ignited a much-needed spark; future work should focus on continued development of nursing/midwifery research capacity.

Responses from deans/directors (the graduates' employers) indicated that they observed positive changes in their graduates' work and work behavior upon return to the faculty role, with overall positive impacts at the schools. Graduates not only used the skills and knowledge gained in the program, but they also shared what they learned with colleagues and others. Two deans/directors identified difficulty with reassimilating graduates if they were challenging toward established leadership and authority. Deans/directors and graduates stressed the importance of graduates returning and completing the MOU with the sending school. Of the 40 graduates able to return to their sending school (excluding the three who died shortly after graduation), 82.5% completed their MOU. Given the investment schools put into supporting faculty to attend the program, it is not surprising that there were recommendations to find ways to enforce the MOU.

The potential global impact of undercapacitated health care workforces in developing countries rose to international concern in 2014 with the reporting of the Ebola epidemic. A skilled health workforce (overwhelmingly represented by nurses) is critical to health security both locally and globally (“No Health Workforce,” 2016). MSNEd students/graduates took on active and critical roles in responding to the Ebola crisis. They volunteered or were hired by agencies or institutions fighting the epidemic in Liberia as educators, leaders, and research personnel. Strengthening the nursing workforce in Liberia—and throughout the world—by improving nursing education will have substantial benefits worldwide.

Because the program recruits students from accredited nursing schools across the country who then return to the sending schools after graduation, the benefit of the program is disseminated throughout the country. As the number of nursing schools continue to grow and current programs expand, an even greater need for quality nurse educators exists. Several participants indicated the desire to see the program continue and grow. However, to become self-sustaining, they identified a need for Liberian nurse educators to attain doctoral level education. Several graduates expressed a desire to pursue a PhD, with the goal of having the highest level Liberian nurse faculty to teach in the program.

Study strengths include the high response rates and collection of both qualitative and quantitative data from graduates and deans/directors. Because the program has only graduated three cohorts thus far, most graduates are still in the early stages of incorporating what they learned into their work, making it difficult to judge the full impact of the program. Time and further evaluation will be needed to assess long-term impact. Having long-term outcome data will offer the program, other stakeholders, and perhaps prospective funders a broader perspective on the extent to which this type of program may strengthen the nursing workforce. The findings are relevant for other countries and contexts where building a well-educated nursing workforce is an urgent priority. Quality nursing education helps scale up the development of nurses and enhances the contribution nurses make to health and health care within Liberia and globally.

Conclusion

The development of well-qualified nursing faculty is critical for the education of future nurses who can meet the ever-growing health care demands with care grounded in current, contextually situated, evidence-based practice. The initial results presented in this study highlight the success of a MSNEd program, offered to current nursing and midwifery faculty from schools across Liberia, in enhancing the teaching and leadership capabilities throughout the country.

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Graduates' Responses Regarding Achievement of Program Outcomesa

ItemnMeanSDRange
I am effective at facilitating student learning.324.880.423–5
I effectively use assessment and evaluation strategies.324.810.473–5
I participate in curriculum design and evaluation of program outcomes at my workplace.333.501.321–5
I pursue quality improvement in the nursing, midwifery and/or the educator role.334.880.334–5
I engage in scholarship. (Defined as generating, utilizing, synthesizing, and/or disseminating knowledge pertinent to nursing education and practice. Engaging in scholarly presentations and publications.)283.251.401–5
I am effective as a change agent and leader.334.760.503–5
I contribute effectively to the development and socialization of future nurses/midwives.324.44.723–5

Deans' Responses Regarding Graduates' Achievement of Program Outcomesa

ItemnMeanSDRange
The graduate is effective at facilitating student learning.334.390.832–5
The graduate effectively uses assessment and evaluation strategies334.450.713–5
The graduate participates in curriculum design and evaluation of program outcomes at my workplace334.340.703–5
The graduate pursues quality improvement in the nursing, midwifery, and/or the educator role.334.420.613–5
The graduate engages in scholarship. (Defined as generating, utilizing, synthesizing, and/or disseminating knowledge pertinent to nursing education and practice. Engaging in scholarly presentations and publications.)333.900.942–5
The graduate is effective as a change agent and leader334.091.011–5
The graduate contributes effectively to the development and socialization of future nurses/midwives.334.210.863–5

Professional Activities Since Graduating From the Program

Professional Activityn%
Gave formal didactic presentations to professional groups (e.g., case conferences, grand rounds, workshops, in-services, trainings)3193.9
Provided education to the public or community2781.8
Gave presentation at a local, regional, national, and/or international meeting2369.7
Served as a trainer2266.7
Worked or volunteered for the Board of Nursing and Midwifery in Liberia2163.6
Served as a consultant1751.5
Worked of volunteered for another nursing, midwifery or other organization1545.5
Initiated or collaborated on a research study1442.4
Authored or coauthored a peer-reviewed publication26
Authors

Dr. Goodman is Professor, School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts; Mr. Beyan is Program Coordinator, Masters of Science in Nursing Education, Mother Patern College of Health Sciences, Stella Maris Polytechnic, Monrovia, Liberia; and Dr. Johnson is Assistant Professor Emeritus, School of Nursing, University of Connecticut, Storrs, Connecticut.

The Master of Science in Nursing Education program was developed in 2010 and directed by Dr. Edna Johnson until 2014. The authors thank Sr. Barbara Brillant, Dean of Mother Patern College of Health Sciences at the Stella Maris Polytechnic University, for her support of this project.

Address correspondence to Janice H. Goodman, PhD, PMHCNS-BC, PMHNP-BC, Professor, School of Nursing, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129; e-mail: jgoodman@mghihp.edu.

Received: March 31, 2018
Accepted: June 21, 2018

10.3928/01484834-20181119-03

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