Challenges in Global Health Practice: how to adapt in uncertain environments while staying true to d
MGHC was thrilled to receive a nursing education project as its first grant as the “Milwaukee Global Health Consortium.” In terms of impact, this project had “sustainability” written all over it. With the ultimate goal of improving clinical skills education for students of two schools of nursing in Mwanza, Tanzania, the project partnered nursing educators in the United States with those in Mwanza to identify key areas of improvement and conduct training. Instead of simply traveling and teaching skills themselves, US nursing educators would work with Tanzanian faculty and preceptors to improve their training on skills performance and increase critical thinking of students. MGHC was drawn to the fact that a significant portion of the project included “training of trainers” so that our team members’ expertise could be shared with faculty and preceptors on the ground who could then train future preceptors as needed. “Perfect,” we thought. If we the international partner needed to come back every year, it wouldn’t be a well-designed project. Nothing is ever easy with international work, but this project had two things going for it: partnership with stakeholders on the ground and an approach meant for lasting impact.
The project involves a teaching hospital and affiliated university, which serve different purposes for students. The teaching hospital offers a diploma program, much like an RN in the United States. The university on the other hand offers a Bachelor’s in Nursing and has a larger emphasis on theory and didactic teaching. The schools rely on one shared clinical skills simulation lab and eight preceptors at the teaching hospital.
US team members include nursing educators and clinical instructors from UW-Milwaukee, Concordia University, and Aurora Health Care. Before traveling to Mwanza, the team expected to focus on several key deliverables:
-Facilitate increased use of the clinical skills simulation lab by assessing equipment needs, developing objective structured evaluations (OSCE’s), and training on OSCE administration and evaluation;
-Improve the impact of clinical rotations by revising clinical logbooks, clinical learning objectives and evaluation guidelines;
-Facilitate the setup of a new external clinical rotation site at a rural hospital by training current preceptors how to train new preceptors; and,
-Offer refresher trainings for clinical nursing preceptors.
It quickly became clear in-country that the greatest challenges to improving clinical skills teaching at the schools are deeper structural issues such as communication and consistency among faculty expectations of students. Creating a thousand clinical learning objectives would make no difference if faculty and preceptors did not have an agreed upon system in which to use them. We could design easy-to-use clinical logbooks tailored to the schools, but the Tanzanian Ministry of Health requires use of a standard logbook. So here was the team’s major challenge working in an environment that was more complex than expected: how do we stay within the project scope while also addressing underlying issues that would make deliverables more acceptable and thus, effective?
Fortunately, our team is made up of not only great nurses, but great educators. Education is a key part of any global health project. After numerous discussions with the schools and the funder, we went back to the drawing board with our contract and added pieces that focused on a mentoring framework. Each part of the project will not only include training on development of a tool (OSCE's, clinical learning objectives, logbooks, clinical evaluations), but training on its use and evaluation as it pertains to all parties – students, faculty, and preceptors. Emphasis is and always will be placed on communication and critical thinking.
It’s tempting in global health work to set up boxes to check off; it’s much more challenging to set the stage in which those boxes will make a lasting impact.
Concordia University nursing educators work with faculty in Mwanza to design OSCEs for their courses.
Sarah Ehlinger Affotey is Program Manager at MGHC. She worked in Tanzania with the team of US nursing educators to conduct a thorough needs assessment before project implementation.