Building the Nurse Workforce with Open Educational Resources

A significant global problem is the shortage of well-trained nurses. Unfortunately, nurse education in Bangladesh is hampered by weak instructional capacity, with insufficient, out-dated resources. Nurse educators are in short supply: many are novices with limited education or experience.

This project’s solution is both high-tech and high touch, supporting nurse educators with technology-focused and delivered Open Educational Resources (OER) as well as remote mentoring to integrate computer literacy with modern adult education principles.

Our team members have 15 years experience helping start a nursing college in Dhaka and have already distributed OER to nurse educators around the world. The Bangladesh partners include a vocational college in a rural district and a well-established NGO operating two hospitals and a home-care nursing program.

This solution can positively change lives by preparing young men and women for well-paying, technology-driven jobs that advance population health through the contribution of skilled nurses and nurse assistants.

In a widely-read previous publication we detailed the  scale of the problem of nurse shortages in Bangladesh. Briefly, for Bangladesh to match the proportion of nurses in neighbouring India would require 120,000 more nurses. This would be about one-tenth the Canadian proportion. 

Since then, contributing factors have led to greater demand for well-trained nurses  in both private and public health services and also for overseas emigration.

1. Technological change in health service delivery creates more opportunities for nurses.
2. Social change means working families need in-home services for elderly relatives and the public wants better acute care services.
3. Rising standards of living bring chronic illness in addition to the existing diseases of poverty.
4. Improved job opportunities for women intensify competition for the best students.

The number of people affected is enormous. As one example, consider the potential impact on youth employment. Educational opportunities, especially in rural areas, are very limited. In our partner organization’s district, the population is over 300,000 in an area of about 300 square kilometres. However, there is no educational institute at any level offering technical or vocational education.  

Our project focuses on educators, but the bottle-neck problem affects all health care workers, patients and employers in Bangladesh.

The population we are directly working with is nurse educators. In turn, they will help students to build professional careers, which will support their families and impact thousands of individual patients in each nurse's working life.

We understand the needs of health care educators and providers because we have been working in Bangladesh since 2003 and with our current partners for 5-10 years.

1. We have helped to develop the hospital programs delivered by Sajida Foundation. We also trained the trainers for their home care program. This helped in understanding the limitations of the nurses available for hire as well as the trainers themselves.
2. For the rural development project, we have participated in four community dialogues and had numerous meetings with NGO leaders.
3. We have recently been approached by a large mother-child hospital to help them start up their nursing college and by a large psychiatric hospital to assist nurse up-skilling.

It is very difficult to recruit nurses from high-income countries to work in the challenging conditions of Bangladesh. By adapting digital technologies to the complex task of health professional education, we can harness global expertise to raise standards of nurse education.

This project will provide through an OER platform the curriculum for an English language, 4 year Bachelor of Science in Nursing (BSN) that includes training in health care technologies and computer literacy. The OER will include lectures, references and resources, plus tools for evaluation and administration.  A mutual support system will be developed from the international community of nurses associated with NI.

The core curriculum includes 20 classroom courses with clinical labs. All courses are based on international standard content, adapted for low-resource settings. This means addressing population health issues as well as differences in social structure, attitudes to learning and professional values. The major topics are medical-surgical, community health, maternal child, mental health, research, professional development, administration and informatics.

The project will include the following tasks to deliver the enabling products:

1. Researching, identifying, and securing access to the best OER for the project.  
2. Refining curriculum to clarify course objectives and aligning them with graduate competencies from the Bangladesh Nursing Council.
3. Developing a teacher’s manual with an emphasis on use of digital technology and on-line resources.
4. Developing appropriate administrative policies for educational institutions (i.e. policies for ethical conduct, research approval, plagiarism etc.).
5. Posting the curriculum and resources on an OER platform with appropriate controls for file management, accessibility, user security etc.
6. Communicating availability of this new curriculum resource to stakeholder groups such as the WHO-Global Alliance for Nursing and Midwifery, HIFA, government ministries and agencies, nursing schools, etc.

This OER will serve the needs of the College of Nursing and professional upgrading of psychiatric nurses. For the rural development partner (OFP), we will develop a sub-set of OER for nursing assistants. This will enable graduates of OFP's vocational school to get jobs with the Sajida Foundation.

The processes and technology require incorporating information and communications technology into the administration and delivery of educational programs within each partner organization. This means overcoming software, hardware and connectivity issues common in low-resource settings.

An associated content problem is introducing dynamic knowledge creation to ensure that each course is based on current best practice. An additional teaching concern is the development of professional comportment ("high-touch" or compassionate care, values formation, accountability, professional identity, ethics etc.) To tackle both these issues, we will develop international communities of practice using social media tools and processes.

This proposed scope of work is notional and we would adapt according to Tiger IT Foundation requirements and recommendations.

Developing the standard BSN curriculum in 2003 was itself an innovation.This content is still unique in Bangladesh for teaching international standard nursing practice adapted for low-resource settings. For local relevance, the syllabus addresses population health issues as well as differences in social structure and professional values. The university’s English medium policy addresses the problem that very few nursing texts have been published in Bangla. The courses use a “scaffolding” or “spiral learning” approach to address the common problems of students’ weak English language skills and poor secondary education. The program results speak for themselves: graduates are often referred to as the best locally-trained nurses in Bangladesh.

The NI-OER is innovative because it will be a complete and integrated package of lecture slide decks and notes, educational tools and policies, assignments and exams, checklists for clinical practice and educator supports. The internet is an abundant source but crammed with “bits and pieces”. For novice educators this can be overwhelming, especially because few have been trained in critical analysis. As part of this project we will enhance educator support with another innovation, using curriculum tracking software to  link concepts across courses.

Additionally, the communities of practice we propose introduce to the Bangladesh context an innovative approach based on collaboration of educators to develop, adapt and share OER as well as engage in dialogue about their experiences and challenges. Our previous experience hosting and funding two conferences showed that nurse educators need and value opportunities for mutual support.

We use several change theories: Lewin’s high-level model (Unfreeze-Change-Freeze) is helpful for our shift in pedagogical approach from teacher-centred to student-centred learning. We have also developed a logic model that includes Inputs, Activities and Expected Result as Outputs Outcomes and Impacts (not included in this proposal; available on request).

For understanding the context, we use Complex Adaptive Systems theory particularly for network analysis and knowledge management. Our strategic analysis of leverage points for change has been published with strong interest in Bangladesh. It includes a review of Bangladesh literature, international comparisons, and consideration of socio-cultural factors based on many meetings with educators, officials and partner organizations. Hence our focus on the “nurse-educator bottleneck” as amenable to a technology-based breakthrough.

Regarding our innovative use of OER, we have worked with the Commonwealth of Learning (COL), a global leader in OER, to develop an evidence-based approach, using student-centred design. Also from COL, we have adopted the concept of “communities of practice” as a way to update the materials without significant cost. Support for nurse education is nowhere available as an OER, so it is our unique contribution. From our experience in Bangladesh, we focus on scientific knowledge and technical skills, plus critical thinking and compassionate practice. This innovation has led to widespread positive feedback about our graduates’ performance in the workplace.

We use the “Collective Impact” framework to define the "backbone" role of our team and to develop collaborative structures and processes with our Bangladesh partners.

This is mostly a virtual service, so measuring use is challenging, let alone "meaningful" impact. We expect to benefit these groups:

Faculty and administrators will be able to make any changes they wish when they organize the syllabus for their own institutes. The OER will be shared using Creative Commons licensing arrangements. Local adaptation will help ensure the OER meets national regulatory standards and practice requirements, within an international framework for easier articulation.

Nursing specialist educators will have access to a larger pool of peers working in the same topic area. Through on-going partnership work, this OER will help focus teams of specialist educators working collaboratively to update and supplement curriculum in their topic area (e.g. maternal child nursing). Instead of working in isolation, the network (or “community of practice”) will be able to respond more effectively to rapid change in healthcare. The network of participants will also be able to collaborate in quality assurance and accreditation activities with mutual trust based on shared resource development. 

  Government officials responsible for higher education and health human resource planning will benefit from the focus on south-south collaboration. This will support national and local development within a framework of basic international standards.

  Novice nurse educators - our ultimate target group - will have access not only to classroom lectures (mostly PowerPoint presentations), but also resource packages, assignments and exams, checklists for clinical practice, and administrative policies. This will assist them as they master the skills necessary to become effective educators.

We propose several phases. Phase 1 is current year work presently underway using volunteer resources. It focuses on development of the OER material.

1. Build Advisory Group, develop work plans.
2. Approach Higher Education Institutes (HEI) interested to participate. (Three, possibly four, in Bangladesh have been identified for the current project.)
3. Form and orient teams of course developers.
4. Create a standardized course template to guide developers. (Mostly complete, will adapt for this project.)
5. Link objectives in each course to overall Bangladesh Nursing Council graduate competencies.
6. Update all lectures, supplying Open Access references and resources.
7. Post the Learning Resources on OER platform.

Phase 2 focuses on Classroom Teaching Resources and Program Resources.

1. Develop the Classroom Teaching Resources (e.g.  teacher notes, case studies and exercises, assessment materials).
2. Develop the Program Resources (e.g.  background documentation for the entire BSN program, including philosophy, goals and policies,clinical assessment tools).
3. Enhance the OER with recorded lectures, demonstration videos and interactive materials.
4. Develop technical resources to support website management.
5. Post the Classroom Teaching and Program Resources on OER website with registration to facilitate network development.

In Phase 3, we will consolidate progress and establish sustainability processes.

1. Develop an evaluation plan to assess use of the OER in various settings.
2. Develop formal mechanisms to engage and activate a community of practice.
3. Develop a formal process for on-going OER up-dates and develop new material for evolving care delivery issues.
4. Develop a voluntary approach among participating HEIs for quality management and accreditation of the OER delivery process.

Financial barriers are a significant concern. Considering the potential impact, we are not looking for much money. The work can be scaled to available resources but volunteer efforts are most effective when supported by dedicated coordination and technical expertise until the proposed income streams are established.

Human resource barriers: So far no problem recruiting North American volunteers, but HR issues are an important barrier/risk for all industries in Bangladesh. In health care there is intense competition for staff and scarce employee loyalty. It will be important to identify, orient and induct and retain a strong team of educators, information specialists and technical staff.

Technical barriers relate to

• Knowledge management: organizing diverse resources with appropriate search and linkage functions; tackling intellectual property, privacy, Creative Commons and copyright issues; addressing varied student skill levels
• Repository management: access, file management and version control capacity and procedures
• Building institutional capacity
• Building individual user capacity: e.g. ICT skills in a variable connectivity environment; e.g.  appropriate skills for use and adaptation of OER
• Organizational capacity: support functions for users and contributors to the OER.

Market risks include

• Credibility: Will the OER nursing curriculum and induction approach be viewed as credible?
• Competition, particularly from proprietary content providers.
• Viability of “premium” paid services additional to the OER that will finance core activities.

We do not consider legal and cultural barriers to be a significant risk because we will work closely with Bangladesh partners and the nurse regulator for guidance.

Financial barriers are acute in this start-up phase. We offer a powerful innovation that is inherently simple (“face validity”) with widespread applicability. With dozens of nurses having volunteered at their own expense to teach in our Bangladesh college, we have demonstrated  the  appeal of our vision. On-going, we are not looking for much money because users will sustain most of the work. Our business model needs refining but we believe it reasonable to raise enough for the backbone organization through “premium” services such as Technical Assistance at the HEI or systems level.

Human resource barriers in Bangladesh can be partially addressed by working with our established and growing number of alumni who are loyal to us and who increasingly occupy leadership roles in HEI and hospitals in Nepal as well as Bangladesh. The nursing college is in a university with a strong computer science college, so we expect to work with those colleagues.

Technical barriers are simpler to and will be addressed through standard project management methods with expert consultation as required.

Market risks related to credibility of the OER nursing curriculum will require engagement with senior officials in HEI and regulatory bodies. This will require both individual and group approaches. Competition, particularly from proprietary content providers has been a problem previously. We have a first-mover advantage if we progress smartly. The Creative Commons approach itself undercuts the risk. We will be making special efforts to educate HEI users about the investments and effort required for systematic development of OER.

The market opportunity is very promising. Bangladesh’s Poverty Reduction Strategy recognizes the shortage of nurses as a barrier to progress in the health sphere and increasing the number of nurses is a major strategic goal. Another major priority is to increase the number of female economic participants at the mid and high levels of the productivity and income scales, as women mostly hold positions at the lower end of these scales.

Our expansion plans would be to demonstrate the benefit of OER for improved production of nurses in these settings:

• The Centre for Woman and Child Health (Savar) has asked for help to start a nursing college on the premises.
• Oasis for Posterity (Jaldhaka) in partnership with Sajida Foundation (Dhaka) has requested help to develop a training program for nursing assistants (paramedics).
• National Institute for Mental Health (Dhaka) would like to create a post-graduate diploma in mental health nursing.

We would use these expansion sites to improve the quality of OER by tailoring it to local need and context of practice. We would also develop associated training products and services to support educators. We would evaluate implementation issues (enablers and constraints), and test various ICT solutions in low-resource settings. The findings from these implementation projects would prepare the NI-OER team for broader expansion in further phases of the work. This expansion would be in Bangladesh and in other countries.

1. The Bangladesh Health Project [BHP] based in British Columbia, Canada is entirely self-funded. BHP is a program of the Mid-Main Community Health Centre, a primary health care centre in Vancouver and a registered charity. In 2003, BHP founders were invited to help develop a College of Nursing at the International University of Business Agriculture and Technology in Dhaka Bangladesh. This was a start-up, meeting requirements of the local regulator, but of necessity employing volunteer visiting faculty until recently. During this process, BHP developed relationships with many of the better hospitals in Bangladesh. Program graduates have taken leadership roles in hospitals and colleges in Bangladesh and Nepal.

2. Nurses International [NI] is a 501.c3 corporation based in Minnesota, USA. NI has developed a community-based BSN curriculum with support from its large network of nurse educator volunteers. NI has developed relationships with technology developers interested in innovative use of technology for OER. NI has initiated nursing college partnerships in Burundi, Egypt and Guatemala, using conventional classroom teaching as well as distance education. Like BHP, NI is funded by donations, with one officer paid part-time to coordinate activities.

The two partnering organizations have already worked together to develop two new courses.

The three principals include one team member from Bangladesh Health Project (30% full-time-equivalent- FTE) and two from Nurses International (80% FTE and 25% FTE). All are volunteering their time. Other team members vary according to project needs, so that a "Course Development Intensive" may include 10-12 volunteer faculty for a day-long session, with follow-up work by each member and coordination by one or two people who work 25% FTE over a couple of months to finalize the OER. Both organizations have access to large pools of committed volunteers built over many years.

Trust is essential for collaboration. BHP volunteers have been working on nurse education in Bangladesh since 2003. Using personal funds, BHP hosted the university’s Vice-Chancellor for stakeholder meetings in Canada and the principals travel to Bangladesh at least annually. Long-term personal commitments have developed based on trust, not because there are financial rewards for the BHP principals. This commitment is valued by all the partners on this project. The BHP principals are seen to understand “how things work” - factors affecting nurse education in Bangladesh and the significant population health challenges where nurses are presently under-utilized.

NI has developed a large network of USA-based nurse educator volunteers who assist with curriculum development and conduct necessary academic work and consulting support for NI’s international projects. Complementing this talent pool, NI has developed relationships with technology developers interested in innovative use of Internet-based technology for OER. Because nursing science is evolving rapidly it is critical to access both up-to-date expertise and the tools to spread new knowledge to educators training young professionals.

Like BHP, NI is a mission-driven organization staffed by social development entrepreneurs. With only limited resources, both groups have learned to be thrifty, creative and enterprising. We recognize the need to become self-sustaining and welcome guidance from the MIT Solvers program to achieve that.

1. Since 2010, BHP has worked with Sajida Foundation (SF), a well-established NGO with impeccable standards of accountability. In its health care programs, SF has encountered the usual HR shortages. SF plans to train workers in its own nursing institute, which will be supported by access to the NI-OER.
2. Since 2008, BHP has worked with Oasis for Posterity (OFP), a grass-roots organization in an impoverished district. BHP raised funds to build and operate a primary school and is helping construct a vocational school, which will train nursing assistants for SF programs.
3. Since 2006, BHP has worked with Centre for Woman and Child Health (CWCH) which is now starting its own nursing college, which will be supported by access to the NI-OER.

Working with these partners will give the project team direct experience in several important areas:

1. Introducing the OER in a remote start-up situation, testing the induction process for both content and ICT skills required of educators.
2. Developing customized modules for a specialty area (assistant nursing) and a dedicated employer of the graduates. This could be a model for NI’s future consulting business.
3. Gaining experience with technology requirements for content management and remote support in low-resource settings.

We provide high-value nursing education curriculum, resources, and support. This effort is led and supported by a coordinated network of committed and screened volunteer experts. By leveraging volunteer talent in an intentional way, we keep our "backbone organization" relatively lean while accessing faculty diversity and expertise not otherwise accessible at this scale, and certainly not at such low cost.

Affordability is a major constraint for accessing quality curriculum and resources. Our OER leverages technological and instructional innovations to make quality nursing education materials accessible regardless of the economic status of individuals and institutions.

The work is currently funded by individual and foundation donors who share our vision. Our next challenge is to develop complementary revenue streams through "premium" products and paid consultancies.

Without belabouring dismal health statistics in Bangladesh, especially for poor people, it is important to emphasize the value of better-trained nurses for the general population. We anticipate benefits for all Bangladeshis through access to improved healthcare,  which will lead to immeasurable economic impact as a result of more productive citizens.

There is significant impact for nurses themselves - mostly women with lower socio-economic status, generally poorly paid. Through our contributions the improved performance of nurses resulting from higher-quality training will elevate public perceptions about nurses, their level of competency and thus their social status; financial rewards are expected to follow.

Employers of nurses also benefit from improved supply of essential human resources to meet increasing public demand for modern health care that is both high-tech and high-touch.

Our goal is to provide the OER without charge because we recognize nurse educators are in no position to purchase. Therefore, it is challenging to create a “path to sustainability” that is not based on grants and donations. (We do expect that our humanitarian mission will continue to attract individual and institutional donor support.)

For greater income security and flexibility, we are considering specialized or “premium” services beyond the basic OER described above:

1. Products and services
   1. Non-standard NI intellectual property such as evaluation materials
   2. Translation from English
   3. Curriculum in specialty topics (post-graduate or employment-based)
   4. Assistance to implement the NI-OER in a new setting
   5. Assistance to meet requirements of regulators or accrediting bodies
    
2. Customers (may be individual units or multi-unit systems)
   1. Government departments responsible for nurse education
   2. Private colleges of nursing
   3. Private health care providers  
3. Pricing options
   1. Flat rate or per student subscription for non-standard content
   2. Contract for agency consultation by NI team
   3. Voluntary subscription for individual OER users
   4. Block grant (e.g. philanthropic support)
4. Marketing options
   1. Professional journals
   2. Platforms that promote open access (HIFA, WikiMed, ISKME etc.)
   3. Public engagements such as conferences
   4. Direct contact through professional associations and networks

We are applying to the Tiger Challenge because our expertise is supporting nurse educators in low-resource settings, not attracting investors in high-resource countries. In the past the concept of OER may have been too innovative in the conservative environment of health provider education. This is changing due to both familiarity with OER and global urgency about health human resources. There is also increasing recognition of the need to engage public and private stakeholders in health service delivery and provider education.

Being selected to advance our work will help us take a different approach.  We believe passionately in our product and have demonstrated meaningful results with an all-volunteer effort thus far. Our partnerships with credible NGOs in Bangladesh provide a powerful base of support for implementation and early impact. We hope to benefit from Tiger IT Foundation’s focus on facilitating broad-based, innovative solutions in the health care space.

Some of the barriers we need to overcome are

• Developing an integrated approach to the curriculum repository to address quality and accessibility goals as well as distribution issues.
• Formalizing the user network into technology-enabled communities of practice that can autonomously advance curriculum development and educator supports.
• Tackling the "last nanometer" issues of user acceptability, familiarity and proficiency with new technology.
• Guiding strategic development for horizon issues such as regulatory compliance, continuing upgrades to benefit from open standards, and quality assurance at institution level.
• Developing business strategy to strengthen self-funding, engage institutional-level donors and investors and attract expertise outside nurse education.

Internationally-oriented health care product suppliers with strong programs for Corporate Social Responsibility, as potential long-term sponsors.

Open access agencies and providers focused on the post-secondary education space, as guides to resources, better practices, policies and technological solutions.

Agencies (public or private) interested in using NI volunteers as paid consultants for the types of non-core projects noted previously.

Foundations looking for programs with significant growth potential.