Nursing Leadership and Capacity Building in the Context of Primary ...

A Canadian-Brazilian Partnership

D?bora Kirschbaum Nitkin, BScN, PhD is Lecturer, and Wilfrida Chavez, , RN, MHSc, DNP (c) is Senior Lecturer, Director International Office, at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.

Health Care ? is a Canadian-Brazilian partnership established in 2009 and implemented in 2010, among the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto (LSBFN) and the Brazilian Ministry of Health (MoH), National Council of State of Health Secretariats (CONASS), National Council of State Secretariats, State Health Secretariat of Mato Grosso do Sul (SESMS), State Health Secretariat of Acre (SESAC), Federal University of Acre (UFAC) and Federal University of Mato Grosso do Sul (UFMS).
Funded by the Pan-American Health Organization (PAHO), the main goal of the project was ?to promote collaborative and sustainable nursing leadership among the Family Health Teams in Brazil?. Guided by a post-colonialist feminist theoretical framework(1), the program development was grounded on a collaborative partnership between LSBFN?s instructors and Brazilian faculty members who jointly developed and implemented a five-month modular program.

The conceptualization of the program was based on a needs assessment and on the input of representatives of all partner organizations. A workshop was held in Toronto, Canada in February, 2010, in which the agreement was formalized.

The objectives of the program were to:

1. Apply the logical model in different local contexts within primary health care, using multiple strategies to identify organizational issues relevant to nursing practice in primary health care, as well as how to plan, implement and evaluate programs using this model.
2. Identify issues related to professionalism, advocacy and ethics as components of collaborative leadership for nursing in Family Health Teams and their importance for planning and implementation of interventions and programs.
3. Plan strategies for community participation in health services and community research in order to offer care that is scientifically and socially relevant and to plan innovations that increase equity in health guidelines and programs.
4. Recognize the impact that organizational, interprofessional and contextual issues have on clinical practice, and how practice can contribute to improvement and achievement of good results when based on standardized information and evidence.
5. Incorporate the use of information technology skills to enhance collaborative work in teams and continuing education.
6. Develop leadership skills necessary for change towards the formation of communities of practice for nurses that work in Family Health Teams, promoting management, clinical education, and initiatives for social participation in the community with a perspective of growth and interdisciplinary collaboration.

Participants

Participants were managers and front line Registered Nurses recruited and selected by the Brazilian partner health care organizations.

A total of 40 participants from Mato Grosso do Sul and 34 participants from Acre enrolled in the program. Their enthusiasm and commitment to engage in the construction and enhancement of future communities of practice focused on fostering the improvement of the publicly funded Brazilian health care system.

Development of the Program

The program?s modules were developed in loco in the two Brazilian states of Acre (North) and Mato Grosso do Sul (Center-West), chosen by the Brazilian MoH and CONASS to satisfy their demands regarding capacity building in nursing leadership. The modular program was structured as follows:

Module I ? Program planning and development in the primary health care context

• Principles of primary health care
• Principles and applications of the logic model within primary health care

Module II ? Collaborative leadership, advocacy and ethics in primary health care nursing

• Appreciative Inquiry ? collaborative leadership
• Political advocacy- valuing of nurses? role
• Professional and Ethical considerations
• Interprofessional and team collaboration

Module III ? Community participation and community-based research in health

Module IV ? Evidence-based practice and clinical case studies in the context of primary health care

Module V ? Consolidation and development of a community of practice

The program was implemented from April to August, 2010, by a team of 09 LSBFN instructors and 10 Brazilian tutors through in-class, on-line and clinical community-based practices. The administrative and pedagogic coordination was shared by one Project Coordinator and one Associate Coordinator of LSBFN and two local coordinators, one in Rio Branco, AC and other in Campo Grande, MS. The logic model, which was introduced in the first model, was used as the organizing framework for the rest of the modules.

During this five-month program, the in-class activities were taught for one week a month by LSBFN instructors, who delivered the classes in English, which were simultaneous translated into Portuguese by an official translator. The readings adopted in the course were papers published by both Brazilian and Canadian scholars or organizations and all translated to Portuguese. These in-class activities were followed by assigned practical activities and readings that were mentored by Brazilian tutors. These arrangements guaranteed the continuity of the teaching-learning process, the individual participant?s growth and the improvement of the students? logic models.

In module one, groups of three or four participants worked to develop logic models under the local supervision of the Brazilian tutors.
The logic model themes were based on the participants? community needs assessment that was validated among their peers, that is their family health care teams and their clients, through a preliminary community-based intervention. The classes and readings supported the reflection about their practices and the instructors? feedback provided input for enhancing their logic model projects step-by-step.

Outcomes

The main objective of the project was accomplished throughout the five-month modular program.
The students? logic models focused on challenges related to their work either as managers or frontline nurses within the family health teams. They explored problems such as health care provision, team work, health promotion and management of clinical issues. These problems are extremely connected to the current scenario of social determinants of health, health concerns priorities and the consolidation of the Brazilian publicly funded health care system. The themes included:

• Violence against women
• Barriers for implementing Men?s Health Care
• Low rates of following up of children living with acute respiratory problems
• Low rates of foot care compliance in diabetes
• Low rates of patients? compliance to hypertension prevention programs
• Low rates of compliance to cervical cancer prevention programs
• Lack of cohesion among family health care teams regarding interprofessional team work

The interventions required for selecting and designing the problem of study step by step enhanced the students? knowledge about their community needs, strengthens, areas of vulnerability and challenges. Students? learning and knowledge production were grounded by concepts such as community empowerment, patient advocacy, professionalism, informed and evidence based practices as a basis for providing sound clinical interventions, along with foundational principles of primary health care and community based participatory research and development were the tools utilized to ground.

Progressively, the development of the students? logic model expressed an interesting mosaic composed by the integration of Canadian perspectives about the key role played by nursing leadership in health care system changes and patient advocacy promotion to Brazilian perspectives focused on interdisciplinary interprofessional teams as assests for promoting and implementing comprehensive and equitable primary health care.

The practical activities developed in groups in between the in-class activities promoted an enhanced sense of collaborative work among the participants. It also created a strong interest in better understanding the local and broad context experienced by their peers and the strategies adopted by them to find alternative solutions for similar problems. The work in groups also fostered the students? skills for working in collaborative teams and their awareness of the potentiality and empowerment resulting from self-management and peer-support. Finally, the active learning methodologies used and the professional web created amongst the participants facilitated the birth of a community of practices that will hopefully build a sustainable leadership among the family health teams in Brazil.

To evaluate each module, a pre and post-test was given to determine starting level of knowledge or understanding at the beginning of each module. At the end of each module, an exactly comparable test was given to determine the extent to which knowledge and understanding has been augmented by the educational intervention .The results of posttests from all modules showed excellent results. Results of course and instructor evaluation for each module were also very positive. The project team employed formative evaluation after each module to review and adjust educational interventions for the modules that follow. The course and instructor evaluations sought feedback on key areas including relevance of course content, teaching-learning methodologies, literature and new knowledge gained, and plans to implement new leanings. Overall, evaluation results were excellent. Themes from participants? feedback include:

• Increased knowledge through a safe learning environment;
• empowerment;
• knowledge and application of political advocacy;
• interprofessional collaboration;
• collaborative leadership, conflict management, and community participation;
• facilitated knowledge sharing and translation through communities of practice.

The program evaluation reflects the students? high satisfaction with their accomplishments. The pertinence of course content, teaching-learning methodologies, literature adopted and instructors and tutors contributions to promoting critical thinking composed the evaluation criteria assessed at the end of each module.

Reference

(1) Anderson J. Gender, ?race?, poverty, health and discourses of health reform in the context of globalization: a postcolonial feminist perspective in policy research. Nursing Inquiry. 2000 7(4): 220-229.

Source: http://www.research.utoronto.ca/brazil-articles/nursing-leadership-and-capacity-building-in-the-context-of-primary-healthy-care/

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