Haitian nursing education: eLearning experiences

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Teaching and Learning in Nursing (2014) 9, 9397EDUCATE, EXCITE, ENGAGEwww.jtln.orgTim J. Bristol PhD, CNE, ANEFHaitian nursing educ1557-3087/$ see front mhttp://dx.doi.org/10.1016/j.ation: eLearning experiencesUsing instructional technology has brought benefits tomany learning environments around the world. As theinfrastructure of Haiti continues to develop and grow, thesebenefits can be realized in nursing education. Through theuse of Web conferencing software, eBooks, and handheldcomputers, nursing care in Haiti can help meet some of thestaggering health challenges faced by the poorest country inthe western hemisphere.The importance of nursing in Haiti cannot be understated.In a country where 90% live below poverty level and 50% ofthe population is illiterate, access to health care is severelylacking in part due to the severe shortage of nurses. Forexample half of all women and children currently are anemic(World Food Programme, nd.).1. BackgroundThe Facult des Sciences Infirmires de Logane (FSIL)nursing school is the first indigenous baccalaureate andmaster's family nurse practitioner (FNP) program in Haiti.Adjacent to the southern coast of the Golfe de la Gonave, inthe city of Logane, the nursing school can be located onmostof the Global Positioning System maps on-line. The school is30km west of the Port au Prince airport, and the trip usuallytakes 2 hours. Currently, there are 115 undergraduatestudents, 19 graduate students, 9 full-time Haitian nursingfaculty, and 7 American and Haitian adjunct faculty that visiton a regular basis (mostly from the United States). The schoolwas founded in 2004 and has graduated 82 students from theundergraduate program (Haiti Nursing, nd.). The nursingschool is governed by the Episcopal University of Haiti.atter 2014 National Organization for Associate Degteln.2014.01.003The undergraduate program is a residential 4-yearcurriculum, whereas the graduate program is hybrid with a3-year plan of study. A majority of students (95%) are on fullscholarship and subsequently are required to work in Haitifor 2 years after graduation. Because Haiti is the poorestcountry in the western hemisphere, going to college is aserious strain for students and their families. While incollege, these nursing students are unable to work to helpprovide food, shelter, and other essentials for themselvesand, just as importantly, for their families. A majority of thestudents have nutritional deficits when arriving to the school;hence, all students are allowed to take part in the school mealplan regardless of their ability to pay.2. Technology availabilityCurrently, through assistance from multiple donors, thenursing school has access to stable high-speed Internet and acomputer laboratory with 17 laptops. Wifi is availablethroughout the main building of the campus when electricityis available. One of the nursing students is hired to helpmaintain the computers and provide faculty support. Thisnursing student receives oversight by one of the nursingfaculty and the dean.All the faculty are issued a laptop. Approximately 10% ofnursing students own a laptop. Handheld tablets andsmartphones are owned and used by 15% of the students,faculty, and staff. These are personal devices and are notsupported by the school.Part of moving the school forward is effectively usingtechnology to meet the educational needs of the learners andree Nursing. Published by Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.teln.2014.01.003http://dx.doi.org/94 T.J. Bristol, H. Alcindorthe health care needs of the community. Some of the currenttechnologies include eBooks, handheld devices, asynchro-nous discussions (ADs), and liveWeb conferencing. For eachinstructional technology, a review of the current need, currentuse, lessons learned, and future plans will be reviewed.3. eBooks3.1. Current needThe need for evidence-based practice cannot be under-stated in Haiti. Because nurses account for a majority of thehealth care available, these professionals need to be able toaccess updated information as part of their studies and theirpractice. Often, nurses and students find themselves inisolated situations where no other health care providers areavailable, leaving them to individually identify best practicesfor the client being served.Another concern is accessing print-based books in Haiti.Current editions of print media are difficult to find. Shippingprint media to Haiti is prohibitively expensive for most of thenurses and organizations, including the FSIL nursing school.These issues make access to eBooks vital.3.2. Current useThe FSIL Nursing School is using eBooks in certainareas. The current concern is limited access to computersloaded with the eBooks and limited access to French eBooks.Less than 10% of the nursing students have their own laptopor tablet that is compatible with eBooks. The eBooksavailable are on computers in the laboratory, which is alsoused as a classroom. This limits access because thelaboratory is used all day every day for class (see Fig. 1).Fig. 1 Marah Armand, BSN, Faculty, assisting nursing studentswith a fundamentals of nursing eBook.The current eBooks (textbooks) are also currently inEnglish. All FSIL nursing students take English throughoutthe 4-year program. However, the English in the textbooks isa struggle for a majority of the students and some faculty.There currently are no French or Creole digital textbooksbeing used. Print-based French nursing textbooks areavailable to the students in the library; however, most areoutdated. The 115 undergraduate students and 9 nursingfaculty share 18 sets of these textbooks.3.3. Lessons learnedWhen students access the eBooks on the computers, manywill use a free on-line service to translate and study smallpassages. Because of the limited access and the languagebarrier, most of the students and faculty treat these textbooksas reference materials as opposed to in-depth study tools.3.4. Future plansCurrent plans include fundraising for more computers andtablets for all students to easily access eBooks in French.There also is an initiative to have more French print-basedmaterial readily available.4. Handheld tablets and smartphones4.1. Current needAccessing the evidence base at the point of care is a vitalneed in Haiti. As was noted before, most of the students andnurses find themselves in isolated situations needing to makeimportant health care decisions. Mobile technology will helpto address this need (Bristol & Zerwekh, 2011; Hebda &Czar, 2012). These devices can have resources downloadedto address concerns such as practice guidelines, pharma-cotherapeutics, skills, and even patient education.Handhelds used in this environment need to have allresources downloaded to the device so that Internet is notrequired at the point of care. Although 3G mobile Internetis becoming more universal in Haiti, there are manyremote regions with no Internet access. These devices alsoneed adequate battery life because access to electricity isnot consistently available. Having an additional battery isalso needed.Devices with voice, texting, and cameras can also beuseful (e.g., basic mobile/cellular phones). Mobile phonescan be used to call or text for consultation and sending apicture. These actions only require basic cellular service toinclude Short Message Service or Multimedia MessagingService texting capability. This service is almost universallyavailable in Haiti. It should be noted that photographs can betaken and saved to the devices and transmitted from alocation with adequate service and connectivity. No 3G orFig. 2 Nursing students working with Health eVillages apps ona loaner iPad in clinical.95Haitian nursing educationInternet is required for most of the voice, texting, andphotograph transmission.4.2. Current useStudents and faculty at the FSIL nursing school traveloften to distant locations where access to resources is limited.Even in the largest Haitian hospitals, students, nurses, andfaculty rarely have access to evidence-based resources andvery limited collaboration opportunities with other healthcare providers. It is for this reason that students and facultyare exposed to handheld technology resources and strategies(see Fig. 2).At the date of this writing, three faculty and one studenthave tablets with clinical resources loaded. Smartphoneswith clinical resources are used by five faculty and twostudents. These are personally owned devices that some-times are used in clinical. Occasionally, visiting faculty willbring a tablet to clinical and expose the students, nurses,and faculty to strategies related to using clinical resourcesat the bedside.4.3. Lessons learnedThrough collaboration with organizations such as HealtheVillages and Skyscape, devices and software have beenidentified that may be deployed through the nursing school.French software has been identified that can be loaded forlow or no cost.5. French resources accessed5.1. iPansementThis application assists health care workers and studentsmanage wounds. The application costs around $8 (https://i tunes.apple.com/fr/app/ipansement/id542196988?mt=8&ls=1).Medical Aid FilmsPatient and health care providervideos in French that can be downloaded at no cost (http://medicalaidfilms.org/our-films/maf-films-en-francais/).Registered Nurses' Association of Ontario InternationalAffairs and Best Practice GuidelinesPractice guidelinescan be downloaded in French at no cost (http://rnao.ca/bpg/language?items=75).SMUR BMPM HDThis application is a collection ofmedication monographs, therapies, and practice guidelines.This application costs $9.99 and is available on iPad andAndroid platforms (http://www.smurbmpm.fr/accueil/).MedicamentsThis application is a medication guide.The cost is $4.99 (https://itunes.apple.com/us/app/notices-medicaments/id412749301?mt=8).5.2. Future plansPlans are underway to pursue grants for additional devicesand financing to cover the fees associatedwith the applications.Students and faculty will continue to explore use of these toolswith the limited access until further resources can be acquired.6. Asynchronous discussions6.1. Current needADs are on-line forums where learners and faculty caninteract. Because the discussions are asynchronous, partic-ipants do not need to be on-line at the same time. Often, theinstructor will post a question, and then, the students willanswer the question when they are able to log into the forum.Use of ADs in on-line learning can help overcome some ofthe educational barriers in the Haitian nursing school (Bristol& Zerwekh, 2011).The lack of nurse educators and effective resources makesaccess to learning difficult. The other barriers to nursingeducation include the logistics and cost of travel. Thisincludes travel for foreign faculty to come to Haiti to helpeducate nursing students.There is a need for more Creole- and French-speakingfaculty especially when using on-line ADs (text-baseddiscussions). However, many students and most of thefaculty speak, read, and write English well. Although thestudents speak primarily Creole and French, they arerequired to take English in all 4 years of the undergraduateprogram. This helps many students when they interact withEnglish-speaking faculty. In the graduate program, most ofthe students are fluent in English and are required to takeadditional language courses. All the faculty in the graduateprogram are fluent in English, and some are fluent in Frenchand Creole.Another point to consider is that most of the students andfaculty use free on-line translation software when managingtheir course work. This has proven useful when students andfaculty are involved in the on-line AD.https://itunes.apple.com/fr/app/ipansement/id542196988?mt=8&ls=1https://itunes.apple.com/fr/app/ipansement/id542196988?mt=8&ls=1https://itunes.apple.com/fr/app/ipansement/id542196988?mt=8&ls=1http://medicalaidfilms.org/our-films/maf-films-en-francais/http://medicalaidfilms.org/our-films/maf-films-en-francais/http://rnao.ca/bpg/language?items=75http://rnao.ca/bpg/language?items=75http://www.smurbmpm.fr/accueil/https://itunes.apple.com/us/app/notices-medicaments/id412749301?mt=8https://itunes.apple.com/us/app/notices-medicaments/id412749301?mt=8image of Fig.296 T.J. Bristol, H. Alcindor6.2. Current useFor the undergraduates, ADs have been used forpharmacology and community health courses. The pharma-cology course was taught by an American nursing instructorwho spoke only English while living in America. The facultyat the nursing school in Haiti administered examinations tothe third-year students. The on-line discussion and on-linecase studies were graded. This grade was combined with theexamination grade by the faculty in Haiti. Although most ofthe students and faculty voiced acceptance of this method-ology, because of scheduling issues, this format has notbeen repeated.Community health was taught by an American nursinginstructor using on-line video and ADs. During the live videofeed, the instructor was teaching students in America andHaiti simultaneously. All students would interact with eachother in the on-line AD forum. All American and Haitianstudents were fourth year baccalaureate students. This courseand methodology is ongoing.In the master's of science FNP program, AD is used for allclasses. An American or Haitian instructor will go to thenursing school in Haiti for an extended weekend and thenteach the students through the AD over the course of 48weeks. This methodology is currently in use for all courses inthe graduate program.The technology needed for the AD includes computers,Internet connectivity, and a learning management system(LMS) for access to a discussion forum. The nursing schoolhas some laptops that are available to all on a limited basis. Afew undergraduate students and most of the graduatestudents have their own laptop. The Internet connectivity isstable a majority of the time unless the electricity is down. AtFSIL, most of the students and faculty experience speeds thatare 10 times greater than dial-up. A few faculty and studentsuse a 3G connection device from the mobile service provider.FSIL uses Moodle for their LMS and ADs. This platformalso houses document submission, grades and, occasionally,quizzes. The LMS is housed on servers in America, andsupport is provided by American technicians.6.3. Lessons learnedThe first lesson learned is that a decision has to be made onhowmuch grammar and punctuation is going to factor into thegrades. Considering that the graduates of these programs willbe practicing in Creole and French, this has been a difficultsubject for the faculty to address. Currently, the nursingstudents in both programs are held to the same standards thatwould be expected in American nursing programs.The second lesson learned is that even though many arefluent in English, the AD can become confusing at times.Using an additional e-mail, telephone call, and video chathelps if students and faculty need additional clarification.Next, understanding the principles of original works (e.g.,avoiding plagiarism) has become a point of discussion aswell. The students need frequent reminders that all workmust be original.Finally, the free on-line translation software is not veryaccurate when nursing terminology is used. All partiesinvolved must carefully assess any translations that comefrom this source.6.4. Future plansPlans are currently in process to increase the use of the ADmethodology for undergraduate and graduate courses. Discus-sions include concerns about increased access to computers forthe students and a larger Internet bandwidth (better speeds).Nursing school faculty are exploring strategies to implementthe AD in student homework for the onsite face-to-facecourses. Faculty are also considering increased visiting facultyinvolved through the use of these tools.7. Live Web conferencing7.1. Current needThe lack of adequate learning resources and facultymakes live Web conferencing (e.g., Webinars, video chat,etc.) an important strategy (Bristol & Zerwekh, 2011). Byusing these tools for teaching, the nursing students at FSILare able to hear from and work with experts and otherlearners. This strategy brings more opportunities for learningrelated to the current evidence base.7.2. Current useCurrently, faculty and students use live Web conferencing.Live video through Skype has helped connect students andfaculty with partners in America. On one occasion, the studentnurses' association from one school of nursing in Tennesseehad a live meeting with faculty and students at FSIL.Some coursework is also delivered with the use of liveWeb conferencing. Community health nursing lecture isdelivered to the FSIL undergraduate nursing students by aprofessor living in Michigan. Through the use of a tool calledVidyo, students interact with the faculty and Americanstudents once a week as part of the community health course.Web conference recordings are also used for facultydevelopment. An on-line faculty development service isdelivered to the FSIL nursing school via Webinar recording.The faculty can listen to the recordings at their convenience.Multiple topics, ranging from clinical teaching to test 318item writing, are included.7.3. Lessons learnedInitially, live Web conferencing was hindered because of aslower Internet bandwidth. Now the stability and speed of theInternet has delivered the performance required to make theseFig. 3 Sophomore nursing student assessing a client in clinical.97Haitian nursing educationvideo connections effective. Another issue is most of thecomputers and laptops are older, so adjustments sometimesneed to be made to help run the videos. One strategy that hasbeen used is to run the live audio over a telephone connectionand allow video to come through the internet.7.4. Future plansThe goal is an increase in live Web conferences to supportthe curriculum. Interest in this initiative includes theincorporation of video into the graduate-level nursingcourses. Using these strategies will help save money ontravel for faculty and provide the school increased access toexperts in certain fields.8. Next stepsThe FSIL Nursing School has experienced opportunitiesand challenges related to using instructional technologythroughout the curriculum. Now that the faculty are beingeducated at the graduate level and more resources forresearch are available to both undergraduate and graduatestudents, conducting outcome-related studies associatedwith technology should begin. Conducting research ofthis nature can help validate the investment of bothfinancial and human resources.Continuing to build relationships with donors and grant-awarding organizations can also assist in the future growth ofeLearning at FSIL. Developing grants to acquire hardwareand software for hospital and community care is vital.Handhelds at the point of care can oftentimes mean adifference in life or death (see Fig. 3).Another strategy currently being explored is on-linetesting. Because of the increased stability of the Internet,on-line testing could save the school in printing expenses.Copies are usually twice as much in Haiti as in Americafor a number of reasons. Grading paper-based examina-tions is also very time intensive. In administering on-linetests, the printing costs would decrease dramatically, andfaculty could better use their time conducting itemanalysis. In order for more on-line testing to be used,the computer laboratory will need to be equipped withmore computers.9. SummaryUsing instructional technology at the FSIL NursingSchool has provided many opportunities for this growingprogram. Continuing to explore possibilities with these toolsand partnering with other organizations will help faculty andstudents with future initiatives. Emphasis should be placedon monitoring the impact of these new strategies andproviding effective faculty development.Tim J. Bristol PhD, CNE, ANEFFaculty, Walden UniversityE-mail address: tim@nursetim.comHilda Alcindor RN, BS, FAANDean, FSIL NursingE-mail address: halcindor@haitinursing.orgReferencesBristol, T., & Zerwekh, J. (2011). Essentials of e-learning for nurseeducators Philadelphia, PA: FA Davis.Haiti Nursing Foundation, (nd.). FSIL Nursing School. Ann Arbor, MI:Author. Retrieved from http://www.haitinursing.org/.Hebda, T., & Czar, P. (2012). Handbook of informatics for nurses &healthcare professionals, 5th ed. Upper Saddle River, NJ: Pearson.World Food Programme (nd.). Haiti. Rome: Author. Retrieved from http://www.wfp.org/countries/haiti/overview.mailto:tim@nursetim.commailto:halcindor@haitinursing.orghttp://www.haitinursing.org/http://www.wfp.org/countries/haiti/overviewhttp://www.wfp.org/countries/haiti/overviewimage of Fig.3Haitian nursing education: eLearning experiences1. Background2. Technology availability3. eBooks3.1. Current need3.2. Current use3.3. Lessons learned3.4. Future plans4. Handheld tablets and smartphones4.1. Current need4.2. Current use4.3. Lessons learned5. French resources accessed5.1. iPansement5.2. Future plans6. Asynchronous discussions6.1. Current need6.2. Current use6.3. Lessons learned6.4. Future plans7. Live Web conferencing7.1. Current need7.2. Current use7.3. Lessons learned7.4. Future plans8. Next steps9. SummaryReferences


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