This document summarizes a needs assessment project presentation for a nursing college in Malawi, Africa. The project aims to: 1) Provide data to support nursing research, education, healthcare infrastructure, and strategic planning for future nursing activities in Malawi. 2) Increase global awareness of nursing education in Malawi. 3) Connect Malawian nursing leaders to the global nursing community. 4) Promote curriculum globalization and awareness of different perspectives in nursing education. The needs assessment focuses on St. John's College of Nursing located in Mzuzu, Malawi which has 111 students enrolled in diploma nursing programs. It seeks to compare Malawian nursing education standards to developed nations and identify correlations

1. 1 A Non- Thesis Project Presentation Submitted in partial fulfillment of the requirements for the degree of: Master of Science in Nursing EducationCollege of Arts and SciencesNursing DepartmentLiberty UniversityLynchburg, VAApril 20th 2010

2. 2 A Needs Assessment Project Presentation for a College of Nursing in Malawi, Africa by: By: Khataza Jessie Wheatley RN BSN

3. 3 Project Introduction

4. Introduction- Malawi 4 Malawi is an east sub-Saharan African country with deficient assets and resources and a largely unskilled personnel (Kelly, 2001).

5. Introduction –Malawi 5 Well known as the "warm heart of Africa” around the region for its friendliest people in all of Africa, this small country boasts a human population of 14 million.

6. Introduction – MALAWI 6 With a life expectancy of only 41 years, Malawi also has one of the lowest life expectancies in the world for its population (Gorman & Hohmuth-Lemonick, 2009).

7. Introduction- Malawi 7 Malawi is a likely site for present and future philanthropy enterprises as it ranks as one of the poorest countries in the world.

8. Introduction –Malawi 8 The healthcare infrastructure in Malawi, has been complicated by issues of poverty, famine and lack of healthcare workers which yield to : One of the world’s worst rates of the Human Immunodeficiency Virus (HIV) and AIDS infection !!

9. Introduction- Malawi 9 It is clearly apparent that nurses and nursing educators in Malawi are challenged by an exaggerated nurse shortage that is at a much bigger scale incomparable to what is seen in most developed nations today.

10. Introduction –Malawi 10 The nursing shortage is due to the Malawi’s numbers of healthcare worker and nurse emigration rates( Taha, 1996).

11. Introduction –Malawi 11 Nursing Training Schools in Malawi Ekwendeni College St. John’s College St. John of God College Mzuzu University Kamuzu College of Nursing ( 2 ) Malawi College of Health Sciences (3) Mulanje College Nkhoma College St. Luke’s College St. Joseph College Trinity College Holy Family College Malamulo College #4 #2 #1 #3 #6A #5a #8 #6C #9 #10 #11 #5B #11 #12 #6B #7 #13

12. Image Shows Hundreds of women and children wait patiently-the occasional temper tantrum aside-for the mobile clinic to arrive in Emazwini, Malawi. (Northern Region) 12 Image: Gorman, Christine; Hohmuth-Lemonick, Eileen AJN The American Journal of Nursing. 109(6):26-30, June 2009. doi: 10.1097/01.NAJ.0000352461.20307.e3

13. Image Shows, Northern Region, Malawi:Embangweni Mission Hospital in rural northern Malawi, nurse WalinaseNdovi takes the temperature of a child who is suspected of having malaria. Thanks to a combination of education, prevention, and treatment efforts, the death rate from malaria among children in this area has fallen dramatically over the past five years 13 Image: Gorman, Christine; Hohmuth-Lemonick, Eileen AJN The American Journal of Nursing. 109(6):26-30, June 2009. doi: 10.1097/01.NAJ.0000352461.20307.e3

14. St John’s Mission Hospital & St John’s College of NursingNorthern Region Malawi Central Africa Dates: January 2010 – April 2011 14 Project setting:

16. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi .

17. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

18. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.15 Project Goal & Objectives:

20. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi .

21. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

22. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.16 Project Goal & Objectives: To allow opportunities for globalization and collaboration in Nursing Education in Malawi by conducting a Nursing School Needs Assessment .

24. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi .

25. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

26. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.17 Project Goal & Objectives: # 1.To provide data that can be utilized for nursing research, education, healthcare infrastructure enhancements & other strategic planning needs for future nursing and healthcare philanthropic activities in Malawi.

28. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi .

29. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

30. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.18 Project Goal & Objectives: # 2. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi

32. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi .

33. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

34. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.19 Project Goal & Objectives: # 3. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

36. To provide an awareness to the global healthcare and nursing community regarding nursing education in Malawi .

37. To permit knowledge and access for the St. John’s College of Nursing and other nursing schools in this region of Africa by providing an entrance platform for Malawi’s nursing leaders into the global nursing professional forum.

38. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.20 Project Goal & Objectives: # 4. To allow opportunities for nursing leaders, students and professionals to learn various ways of enhancing curriculum globalization and awareness of worldviews that pertain to nursing and nursing education.

39. St. JOHN’S HOSPITAL- MZUZU, MALAWI Is a 215-bed Mission Hospital established in 1962 by the Catholic order sisters. 21 Project Setting- The Hospital

40. Project Setting- The Hospital 22 ST. JOHN’S HOSPITAL- MZUZU, MALAWI It has a large catchment area that includes the City of Mzuzu and the surrounding countryside. It has a Male, a Female, a Pediatric, a TB, a Maternity, a Premature Baby Unit and a Nutrition Unit. The maternity unit delivers about 2000 babies a year. A small pharmacy, a small laboratory, an X-ray department and an Operating Theatre providing basic specialized medical care.

41. Project Setting- The Hospital 23 ST. JOHN’S HOSPITAL- MZUZU, MALAWI It has a large catchment area that includes the City of Mzuzu and the surrounding countryside. It has a Male, a Female, a Pediatric, a TB, a Maternity, a Premature Baby Unit and a Nutrition Unit. The maternity unit delivers about 2000 babies a year. A small pharmacy, a small laboratory, an X-ray department and an Operating Theatre providing basic specialized medical care. It has a large catchment area that includes the City of Mzuzu and the surrounding countryside

42. Project Setting- The Hospital 24 It has a Male, a Female, a Pediatric, a TB, a Maternity, a Premature Baby Unit and a Nutrition Unit. The maternity unit delivers about 2000 babies a year. ST. JOHN’S HOSPITAL- MZUZU, MALAWI It has a large catchment area that includes the City of Mzuzu and the surrounding countryside. It has a Male, a Female, a Pediatric, a TB, a Maternity, a Premature Baby Unit and a Nutrition Unit. The maternity unit delivers about 2000 babies a year. A small pharmacy, a small laboratory, an X-ray department and an Operating Theatre providing basic specialized medical care.

43. Project Setting- The Hospital 25 ST. JOHN’S HOSPITAL- MZUZU, MALAWI It has a large catchment area that includes the City of Mzuzu and the surrounding countryside. It has a Male, a Female, a Pediatric, a TB, a Maternity, a Premature Baby Unit and a Nutrition Unit. The maternity unit delivers about 2000 babies a year. A small pharmacy, a small laboratory, an X-ray department and an Operating Theatre providing basic specialized medical care. A small pharmacy, a small laboratory, an X-ray department and an Operating Theatre providing basic specialized medical care.

44. ST. JOHN’S COLLEGE OF NURSING, MZUZU, MALAWI 26 Project Setting- The Nursing School

45. Project Setting- The Nursing School 27 Students & Staff A College of Nursing located at the Hospital with 111 nursing students currently enrolled in a Diploma Nursing Program specializing in a three-year study for Nurse & Nurse Midwife Technician Programs. First-year Students – 26 Second-year Students- 38 Third-year Students- 47 (Male: Female Ratio- 3.7) The College has 12 academic staff (tutors) which includes a Volunteer Services Organization (VSO) volunteer, a College Principal and 3 Clinical instructors.

46. 28 Statement & Significance of Nursing & Nursing Education Issues in Malawi Why Malawi? Why Nursing? ……. One may choose to wonder.

47. Statement and Significance of Nursing Education Issues in Malawi 29 Malawi has the lowest ratios of Healthcare Workers to Total Patient Population in the world. only 7,264 nurses are serving Malawi’s 14 million people. (? Reference) Malawi is the poorest country in the world, with a gross domestic product (GDP) of less than $200 per capita. Malawi has been hardest hit by two of the world’s current worse epidemics: proliferating rates of HIV infection, AIDS and Tuberculosis (TB) infection (Kelly, 2001).

48. Statement and Significance of Nursing Education Issues in Malawi 30 Malawi Aid Workers focusing on Healthcare realize that philanthropic opportunities to assist in Malawi must involve all healthcare workers, including the global professional body of nursing that includes nursing educators and current nursing students. Issues of nursing education in Malawi need to be addressed. These issues can best be addressed by active collaboration with global leaders and students currently actively participating in shaping nursing education worldwide.

49. Statement and Significance of Nursing Education Issues in Malawi 31 This needs assessment serves as a stepping stone to opportunities that will assist the stabilization and standardizing nursing education at St. John’s College of Nursing in Malawi to ensure the quality and integrity of the global body of professional nursing

50. Statement and significance of Nursing Education Issues in Malawi 32 This needs assessment study serves to provide much needed data, not only for Malawi but also for the Sub-Saharan Africa region. In response to this, it is time for nursing leaders and educators to pay close attention to issues affecting nursing education on the global front. By bringing Malawi’s nursing issues to focus with this project and the implementation of further action, we will enhance and unify the profile of the body of the nursing profession in our world and address some very important and complex issues that are affecting world health outcomes today.

51. A review of literature using the CINAHL and OVID databases was conducted using the key terms: international nursing and Malawi,; nursing in Malawi; global nursing issues; nursing migration,; nursing education in Malawi; nursing education issues in Malawi and nursing issues in Malawi. 33 A Review of Literature

52. A Review of Literature 34 that very few studies have been conducted that are specific to nursing and nursing education in Malawi.

53. A Review of Literature 35 Previous studies have focused on other issues; such as: the positive practice environments for international nurses migrating out of countries like Malawi; the ethical recruitment of foreign-trained nurses (Adams & Kennedy, 2006).; nursing work-force self sufficiency and sustainability in countries (like Malawi) where there has been an increase in RN and/or nurse emigration (Little & Buchan, 2007). It is apparent, by review of literature that the global nursing community is aware of such issues as: the massive migration of the healthcare labor force out of poor countries (like Malawi) to developed countries and have published suggestions for the management of issues related to its impact (Stillwell et. al., 2004); the need for accurate data collection methods to track the migration trends (Diallo, 2004); The characteristics of the work of internationally-trained RNs (like those out of Malawi) are also discussed in studies (Xu & Kwak, 2007). Other studies focus on migration and credentialing issues of foreign-educated nurses (Bieski, 2007), There are studies on specific issues that employers of foreign-trained nurses face, such as: competency, communication and consistency in education preparation (Parrone et. al., 2008). According to Parrone et. al (2008), ambiguous and inconsistent education standards for registered nurses that vary from nation to nation may leave out key topics in nursing education preparation, such as patient advocacy, confidentiality issues, Kubbler- Ross research on death and dying etc. Many studies have not focused on the need for transparency in topics regarding RN education in countries around the world.

54. A Review of Literature 36 There is an obvious gap in current research literature on nursing education and practice environment issues in developing countries like Malawi, despite the growing number of emigrating RNs needing to practice in other countries worldwide. The answer to fill this gap lies in conducting research and project s such as this one.

55. In what ways do standards of nursing education in Malawi compare to the schools in developed nations? What possible correlations exist between suggestions for improvement in Malawi’s nursing schools (“Please describe what would most increase your overall level of satisfaction with your nursing education and nursing practice experience here in Malawi”) and resources which are marked with both the highest importance and the lowest level of satisfaction? 37 Research Questions: The project attempted to answer the following

56. In what ways do standards of nursing education in Malawi compare to the schools in developed nations? What possible correlations exist between suggestions for improvement in Malawi’s nursing schools (“Please describe what would most increase your overall level of satisfaction with your nursing education and nursing practice experience here in Malawi”) and resources which are marked with both the highest importance and the lowest level of satisfaction? 38 Research Questions: The project attempted to answer the following Question # 1: In what ways do Standards of Nursing Education in Malawi Compare to the Schools in Developed Nations?

57. In what ways do standards of nursing education in Malawi compare to the schools in developed nations? What possible correlations exist between suggestions for improvement in Malawi’s nursing schools (“Please describe what would most increase your overall level of satisfaction with your nursing education and nursing practice experience here in Malawi”) and resources which are marked with both the highest importance and the lowest level of satisfaction? 39 Research Questions: The project attempted to answer the following Question # 2: What possible correlations exist between Suggestions for Improvement in a Malawi Nursing School and Resources which are marked with both the Highest Importance and the Lowest level of Satisfaction?

58. In the attempts to answer the first research question, there was no intention for the manipulation of the variables under study, nor was there a need to establish causality among variables that were isolated, hence dependent and independent variables were not isolated (Barnes & Grove, 2005). The key variables of interest to answer the first question in this project were sub-divided into these main categories: (1) Demographic Information Characteristics, (2) High School (Secondary) Education Characteristics, (3) Post-Secondary Education Characteristics, (4) Professional Nursing Education Characteristics, (5) Prior Health-Related Education Characteristics, (6) Professional Development Studies Characteristics (7) Professional Licensure Requirements 40 Methodology

59. Data for the second question was collected utilizing the following methods: a written survey (questionnaire) given to nursing students. a face-to-face, telephone, and e-mailed interviews with the nursing school principal and the college librarian. a nursing student focus group. through on-site observations. 41 Methodology

60. The type of research design selected for this project was a Comparative Descriptive Design (Barnes & Grove, 2005). In this design, there was examination and description of several key variables of interest as they occured naturally in their natural setting in Malawi. The rationale for selecting this design is that at this early stage of research on this subject matter there, is such a need to establish a clearer delineation of the Standards of Nursing Education in Malawi before the Second Research Question or any studies such studies that would establish causality could be explored. It is very imperative that Descriptive Research, such as one, be conducted first on this subject matter at this time so that opportunities for further research in Nursing in Malawi can be explored. 42 Project Design

61. The initial participants of this project were obtained through Convenience Sampling Methods. Study participants were accessed through contacts made while visiting the School of Nursing in Mzuzu, Malawi in May 2010. The attrition rate for the sample was ~10 %.The sample was further be expanded and maintained utilizing network sampling methods that included maintaining contacts from the original convenience sample. The total number of subjects studied was 124 individuals. This included nursing faculty and staff, and students at St. John’s College of Nursing. 43 Sample & Sampling Procedures

62. Microsoft Excel was used to create a spreadsheet of the raw data collected for the research questions. Ease/Impact Matrices were utilized to analyze the data collected to and to allow brainstorming by project participants and or other nursing professionals seeking to implement additional actions to solve problems that were identified in this project. 44 Data Analysis

63. 45 Project Findings

70. Suggestions For Future Projects & Research 61 Tuition support Ease/ Impact Matrix Nursing Learning Facilities Improvements to yield: Better hospital facilities and supplies Better dormitory living environments, bedding etc. Better utilities

71. Suggestions For Future Projects & Research 62 Tuition support Ease/ Impact Matrix Improvements to Yield Better Nursing Learning Supplies: Better computers for library research Better simulation, mannequin, equipment etc. Better and more newer textbooks

72. Suggestions For Future Projects & Research 63 Tuition support Ease/ Impact Matrix Improvements to Yield Better Nursing Learning Opportunities: Improvement in nursing facilities and supplies Computers and medical equipment

73. Suggestions For Future Projects & Research 64 Tuition support Ease/ Impact Matrix Improvements to Yield Better Nursing Learning Staff: Better faculty resource support. Availability of professional development opportunities

74. Suggestions For Future Projects & Research 65 Tuition support Ease/ Impact Matrix Improvements to Yield Better Nursing Learning Procedures and Affordability: Opportunities to practice what is learned in textbooks. Better Tuition support

75. References 66 Adams, E. & Kennedy, A. (2006). Positive practice environments. International Centre on Nurse Migration (ICNM). Retrieved February 19, 2009 from http://www.intlnursemigration.org Andrews, M.M. (1992). Cultural perspectives in the 21st century. Journal of Professional Nursing, 8, 7-15. Retrieved January 20, 2009 from CINAHL database. Arnold, L., Bakhtarina, I., Brooks, A.M., Coulter, S., Hurt, L., Lewis, C., Weinstein, S., & Younger, J. (1998). Nursing in the newly independent states of the former Soviet Union: An international partnership for nursing development. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 203-208. Retrieved January 20, 2009 from CINAHL database. Barnes, N., & Grove, S.K., (2005). The practice of nursing research: Conduct critique, and Utilization (5th ed.) St. Louis: Elsevier Saunders Bieski, T. (2007). Foreign-educated nurses: An overview of migration and credentialing issues. Nursing Economics. 25, (1), 20-34 Davidhizar, R., Dowd S.B., & Giger, J.N. (1998), Educating the culturally diverse healthcare student. Nurse Educator, 23, 38-42 Diallo, K. (2004). Data on the migration of health-care workers: Sources, uses and challenges. Bulletin of the World Health Organization. 82, 601-607 Freda, M. C., DeVore, N., Gibeau, A., Griggs, S., Valley-Haye, S., & Russell, B. (1998). An effort to upgrade perinatal nursing practice in Albania. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 209-213 Gorman, C. & Hohmuth-Lemonick, E. (2009) At work with Malawi’s nurses. American Journal of Nursing109, 26-30

76. References 67 Kelly, P.M. (2001). Local problems, local solutions: improving tuberculosis control at the district level in Malawi. Bulletin of the World Health Organization. 70(2), 111-117 Little, L., & Buchan, J. (2007). Nursing self-sufficiency/sustainability in the global context. International Centre on Nurse Migration (ICNM). Retrieved February 19, 2009 from http://www.intlnursemigration.org Maher, A. B. (1992). Supporting education within the international nursing community. Orthopedic Nursing, 11, 8 Parrone, J., Sedrl, D. Donaubauer, C., Phillips, M. & Miller, M. (2008). Charting the 7 C’s of cultural change affecting foreign nurses: competency, communication, consistency, cooperation, customs, conformity and courage. Journal of Cultural Diversity. 15, (1), 3-6 Polsky, D., Ross, S.J., Brush, B.L., Sochalski, J. (2007). Trends in characteristics and country of origin among foreign-trained nurses in the United States, 1990 and 2000. American Journal of Public Health. 97, (5)895-899 Stilwell, B., Diallo, K. Zurn, P., Vujcic, M., Adams, O. & DalPoz, M. (2004). Migration of health-care workers from developing countries: strategic approaches to its management. Bulletin of the World Health Organization. 82, (8), 595-600 Taha, T.E. (1994). Research on human immunodeficiency virus (HIV) in Malawi: the John Hopkins University- Ministry of Health (JHUMOH) project. Malawi Medical Journal, 10 (1) 6-11 Xu, Y. & Kwak, C. (2007). Comparative trend analysis of characteristics of internationally educated nurses and US educated nurse in the United States. International Nursing Review. 54, 78-84