Education is constantly evolving, affected by globalization, information technology advances, and renewed attention to quality improvement in outcomes. Worldwide, nurses and midwives serving as front-line caregivers comprise the largest segment of the health care workforce (World Health Organization [WHO], 2016a). Their education is critical for health system transformation and for promoting health as a human right. The value of transformation has been acknowledged by education research as an opportunity for rethinking the appropriateness and success of educational practices (Filho et al., 2018). In this direction, several global organizations have recommended scaling up transformative and lifelong learning for nurses and midwives (International Confederation of Midwives, 2017; International Council of Nurses, 2017; WHO, 2013). There is also growing impetus to build on the WHO Global Strategy on Human Resources for Health (WHO, 2016a) to prepare nurses and midwives for practice in a rapidly changing environment, assessing evidence, and working collaboratively with other health care professionals to meet the needs of diverse populations (International Confederation of Midwives, 2017; International Council of Nurses, 2017). Most recently, the Nursing Now campaign challenged education leaders to reexamine the preparation of their graduates by redesigning curricula and adopting innovative teaching techniques (Crisp & Iro, 2018).
Latin American and Caribbean (LAC) countries are severely affected by a shortage of adequately qualified nurses and midwives—particularly in underserved areas—negatively affecting individual and population health outcomes (Pan American Health Organization [PAHO], 2017). Amidst growing evidence that well-trained and empowered nurses and midwives can make a difference through the provision of high-impact and low-cost interventions (Crisp & Iro, 2018; WHO, 2016a), strategies to strengthen the quality of nursing and midwifery education have been identified by PAHO (2017) among the top priorities for the region. Thus, the overarching goal of this project was to strengthen the capacity of nursing and midwifery educators in LAC countries by addressing the following educational quality improvement (EQI) priority needs, identified in a previous survey by Cassiani et al. (2017): (a) strengthening competencies on quality monitoring, evaluation, and improvement plans; (b) expanding use of clinical simulation and virtual training; and (c) promoting experiential learning for complex and systemic thinking, and evidence-based decision making. Our operating hypothesis was that user friendly and culturally adaptable online learning courses can be effective EQI interventions that encourage transformation and lifelong learning.
In line with recommendations for open-access, Web-based faculty development programs (WHO, 2013), our self-directed course was built on nurse and midwife educator core competencies that promote a culture for lifelong learning (WHO, 2014, 2016b). The course consisted of three sequential modules, introducing key principles of teaching and learning, instructional strategies, and methods to evaluate students and courses. All three modules in the online course were linked to transformative education, demonstrated by critical and complex thinking, problem solving, evidence-based clinical decision making, and lifelong learning (Frenk et al., 2010).
Generation Z students, born between the mid-1990s and the early 2000s, make up 32% of the global population, have used technology their entire lives, are comfortable multi-tasking, and typically get bored easily (Kuhn, 2019). As a result, instructors need to include a variety of learning activities to keep them engaged. However, nurse educators often have no formal training in best teaching practices, tend to teach as they were taught, and rely on long lectures to convey content (Betihavas, Bridgman, Kornhaber, & Cross, 2016; Levey, 2016; Price, Whitlatch, Maier, Burdi, Peacock, 2016). This misalignment can result in ineffective learning outcomes that could lead to poor student outcomes. Using active learning strategies can result in improved examination scores and can help students gain competency (Della Ratta, 2015; Shin, Sok, Hyun, & Kim 2015). Yet, nurse educators need more training to design activities that promote student engagement, rather than relying on teacher-centric lectures to deliver content. To this direction, this self-learning course was a step toward bridging the identified gaps.
Initial Course Development
Course development was based on the five-step ADDIE process that is widely used by instructional designers to ensure alignment of learning objectives, activities, and assessments (Hess & Greer, 2016). This process entails Analyzing learning objectives and student needs, Designing learning activities and assessments, Determining how to deliver course content, Implementing the course, and Evaluating course effectiveness as part of an iterative process of continuous educational quality improvement (Hess & Greer, 2016).
With surveyed areas for improvement in mind (Cassiani et al, 2017), a group of experts from nursing and midwifery competency-based education, curriculum and instructional design, languages, and library science were assembled from three partnering PAHO/WHO Collaborating Centers (WHOCCs): two from North America and one from the Caribbean. This team completed the first three steps of the ADDIE process by analyzing objectives and needs, designing activities and assessments, and determining delivery of course content. For consistency with previously commissioned work, the PAHO Virtual Campus for Public Health structure for self-learning courses was followed for both English and Spanish versions (PAHO, 2016).
Step 1: Analyzing Objectives and Needs
A predesign team, enhanced by an international visiting scholar from an LAC with extensive online course delivery and teaching experience, used brainstorming and modified affinity grouping techniques to generate, categorize, and choose among ideas targeting the surveyed areas for improvement. A first draft course outline with four proposed modules, objectives, and corresponding content was produced. Upon deliberation, the four modules were combined into three. After matrix consensus was reached, suggestions for further development with supporting material, hyperlinks, and easy, user-friendly course instructions were made. These were coupled with recommendations for professional development, and instructional technology team consultations for elements such as course design, images, tables and figures, and proposed interactive activities.
Step 2: Designing Activities and Assessments
The team developed three sequential online educational modules focusing on aspects of quality improvement in nursing and midwifery education program outcomes (Table A [available in the online version of this article]). Each team member took responsibility for drafting content for select objectives. Educational psychology elements, such as positive reinforcement, were used similarly to electronic games, where mastering one content area by achieving a perfect score unlocked the next module.
Following an iterative process, key elements were selected and connected to optimize course flow. Each module included a 10-item pre- and posttest assessment quiz and followed the same format: objectives, outline, content, references, and resources. Learner engagement was central through the integration of a variety of videos, cognitive aids, graphics, and online resources. Assignments or self-directed learning activities were included throughout the course to highlight key aspects.
Module 1: Principles of Learning: Foundations for Quality Nursing and Midwifery Education. Laying the foundation for nurse educators to become an expert teacher requires an introduction to seminal and emerging theories in education. Understanding “why” and “what” is essential knowledge for quality improvement in nursing and midwifery education. Thus, the questions “Why I should become an innovative teacher?” and “What strategies can improve instruction quality?” guided content development under (a) educational theories and (b) the foundations of learning.
Module 2: Instructional Strategies for Quality Education. Nurse and midwife educators use a variety of teaching strategies to engage students and achieve learning objectives. Module 2, organized in three parts, aimed to describe basic strategies for teaching in classroom and clinical laboratory settings. Part A focused on classroom teaching methods, which included instructional strategies, lesson plans, and active learning strategies. Part B described clinical simulation and experiential learning. Simulation experiences support students in applying their knowledge in a safe environment, with no harm to patients, and can allow independent decision making. Finally, part C described clinical teaching strategies for the nurse educator to become an effective clinical faculty. These strategies are viewed as tools with a dual role: assisting nurse educators in planning and implementing a clinical experience, and helping students make connections from the classroom to the clinical setting.
Module 3: Strategies to Evaluate Students and Courses. This two-part module aimed to build capacity in evaluating students and distinguishing between formative and summative evaluation techniques in the classroom and clinical setting. Part A included methods for classroom evaluation (e.g., essays, team projects, and portfolios) and best practices for item writing and test construction. Accurately evaluating a student's performance and using an appropriate method are essential skills for educators. Part B included a discussion about the importance of performance evaluation in the clinical setting, describing the use of appropriate feedback techniques when conducting any formative and summative evaluations of students.
Step 3: Determining How to Deliver Course Content
External Review and Reconciliation. After the content was developed, three experts in distance-accessible teaching with experience in course development for the LAC region were invited as external reviewers. Detailed comments, suggestions, and tracked changes in the actual module files were sought. Through cognitive debriefing, feedback and recommendations for modifications were collected during a live virtual interview, with two investigators asking questions and recording responses. Any difficulties experienced by respondents, such as asking for clarification, being ambivalent, or skipping items were recorded and used to modify the first course version. Next, qualitative content analysis of data collected through this iterative process was applied, with electronically tracked changes and added comments considered as part of the review process. Researchers reconciled reviewers' input and data to agree on a final version of the online course.
Translation and Cultural Adaptation. After the final English version was reconciled, a native Spanish speaker with experience in health care translations translated all three modules based on the Royal Spanish Academy grammatical rules (Real Academia Española, 2019). To account for linguistic and cultural differences in norms and values, select wording and content was modified, supplemented, or removed. Following completion, a second native Spanish speaker from LAC reviewed the forward translation for linguistic accuracy, cultural relevance, and adaptability. An indicator of “a person's ability to adapt to culturally diverse situations and experiences” (Earnest, Rosenbusch, Wallace-Williams, & Keim, 2016, p. 76), cross-cultural adaptability ensures that course design or content has not created unintentional barriers for users. Last, a reverse translation was performed from Spanish into English with no discrepancies found.
Instructional Design Modification. After content was finalized, an instructional designer loaded all materials into the Canvas learning management system (LMS), with content organized into categories (objectives, learning activities, and assessments) and presented in a user-friendly design template to ensure effortless navigation. Graphics were sized, audiovisual material was captioned, links were checked, and quizzes were loaded and tested. Public access was secured through a WHOCC website landing page for both the English and Spanish version of the course.
Based on identified EQI needs throughout nursing and midwifery schools in LAC countries (Cassiani et al, 2017), the expert group built an introductory lifelong learning course that could spearhead a series of future courses tailored to specific professional development needs. Course development was guided by the principles of (a) usability of information technology for learning, (a) effectiveness in meeting learner needs, and (c) cultural relevance and adaptability. The project team ensured that course tools and links were visible and active, content was readable, and navigation instructions were clear. However, user-centered design models call for testing by those who will navigate the course (Fisher & Wright, 2010). This course was designed as asynchronous, with no interaction or feedback for learners besides automated quiz grading. Examples of instructional strategies, such as active learning or flipped classroom approaches, were included with the assumption that they could be adapted into various cultures, if needed. Therefore, it is essential that we understand from users about what they learned and how they implemented learning into their teaching practice.
Completion of ADDIE steps four (implementation) and five (evaluation) is planned in the near future to solicit feedback regarding learners' ability to work through the course materials in an online asynchronous environment. Our team intends to pilot test and evaluate this newly developed online course for English-speaking and Spanish-speaking nurse and midwife educators at two LAC pilot sites. Results will provide valuable feedback about learners' ability to access content and accomplish the learning objectives, as intended. The course's multilevel approach is expected to (a) increase individual capacity of nurse and midwife educators, (b) leverage EQI change across learning environments, and (c) strengthen partnerships with schools of nursing and midwifery in LAC countries by providing a standardized framework for joint course piloting, evaluation, and planning of future activities in the region.
This evidence-based course, developed according to proven instructional design standards and a reciprocal WHOCC partnership, attempts to meet the needs of Generation Z learners. Nursing and midwifery educators were guided on how to incorporate targeted innovative teaching strategies, including instructional strategies for students with diverse learning styles and a variety of ways to assess student mastery. Content and design were externally reviewed and culturally adapted. Embedded Web links, videos, self-directed learning activities, and resource libraries engaged learners with the content and allowed them to progress at their own pace. The final English and Spanish versions, loaded into the Canvas LMS, are expected to become freely available after pilot testing and evaluation are complete.
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