Matching Supply with Demand

Helping Zambian Youth Fill the Nursing Shortage in Zambia through E-Learning

A Case Study

Introduction

The Zambian Nurse Training and Life Skills Program (ZNLTP) led by ChildFund International in partnership with Mastercard Foundation and African Medical and Research Foundation, addresses Zambia’s growing health care demands using an e-learning model. The program took a collaborative approach to addressing the youth employment challenge by also addressing the existing shortage of trained nurses in Zambia. In addition, the ZNLTP has been able to shift mindsets at all stakeholder levels on the use of e-learning as a pre-service training tool. The program contributed to shifting policies in Zambia in support of e-learning and technology within the broader health sector.

This case study:

  • Explores how the program has changed the perception of e-learning and technology in the health care sector;
  • Outlines some considerations on the sustainability of the e-learning pre-service training in Zambia;
  • Provides lessons for policymakers, governments, NGOs, and other stakeholders interested in implementing scalable and sustainable e-learning programs; and
  • Highlights successes, challenges, and considerations for the future.

Findings from the study are presented within the themes of shifted mindsets around e-learning, policy influence, and potential for sustainability.

ZNLTP has shifted mindsets at all stakeholder levels on the use of e-learning as a training tool. The program contributed to shifting policies in Zambia in support of e-learning and technology within the broader health sector.

Background and Context

Zambia is a very young country.

Seventy-four percent of its population of almost 16 million is under the age of 30, and 57 percent are aged 19 years or younger (United States Census Bureau).

Zambia also struggles with high rates of unemployment and vulnerable work.

  • According to the World Bank, 78 percent of those working in Zambia are vulnerably employed.
  • The estimated youth unemployment rate is 14 percent in 2016.
  • Informal employment is more common than formal employment for this age group (YouthMap).

Three-fourths of Zambia's population is under the age of 30.

Zambia also faces challenges in meeting increasing health care needs. While the number of clinics and hospitals in the country has increased, the supply of qualified nurses has not been able to match the demand.

The World Health Organization (WHO) found that there are just seven nurses and midwives for every 10,000 people, and the Zambian Ministry of Health (MoH) announced a deficit of 6,000 nurses in 2016.

The supply of qualified nurses has been constrained by the limited physical infrastructure to support nursing students as well as high nurse turnover and burnout. The nursing system is in dire need of increased staff to ensure health care demands are met.

The ZNLTP was established as a response to both drivers: the nursing shortage, and precarious youth employment.

 

While the number of clinics and hospitals has increased, the supply of qualified nurses has not been able to match the demand.

Methodology

This case study documents the experiences of stakeholders in three of the pilot schools where the ZNLTP has been implemented: Livingstone School of Nursing, an early adapter and high performer; Ndola School of Nursing, a good performer; and Mufulira School of Nursing, which experienced some challenges. Selecting schools with different performance levels ensures the capture of a range of experiences that may be more representative of all 11 schools where the ZNLTP is currently being implemented.

In order to obtain multiple perspectives and provide a holistic view of the implementation of the ZNLTP, this case study relied on sampling a range of project stakeholders:

  • High-level officials at the Ministry of Health (MoH) and General Nursing Council (GNC)
  • School officials and staff (e.g., Principal Nursing Officer, Principal Tutor, E-Learning Coordinator, Clinical Instructors, Mentors, Tutors)
  • Students (3rd year and 1st year, e-learning and in-person)
  • Nurse employers (both private and public)
  • ChildFund staff

The sample size included 103 people (32 men, 71 women) in four locations in Zambia: Lusaka, Livingstone, Mufulira, and Ndola. Most of the school staff had extensive experience in their positions and had worked with the e-learning students over the past four years, since the program began. A total of 18 key informant interviews (KIIs) were conducted with actors that have specific areas of expertise or knowledge in a one-on-one setting. An additional 16 focus group discussions were held with groups of stakeholders from the same category.

Overview

The ZNLTP takes a holistic multi-stakeholder approach to pre-service nurse training that utilizes e-learning to respond to the demand for nurses and create employment opportunities for the growing youth population. By building on the existing political will for e-health in Zambia, the program is designed to be integrated, scalable, and sustainable.

Launched in 2013, the program is the first of its kind. The main objectives of the ZNLTP are to:

  • Increase the capacity of nurse training institutions to accept a greater number of students into the nursing program to meet health care demands via the provision of pre-service e-learning training for nursing students; and
  • Increase youth’s life skills and psychosocial well-being so they can negotiate barriers to success in the workplace.

Stakeholders Engaged in the ZNLTP

Relationships with key stakeholders, including the MoH, General Nursing Council of Zambia (GNC), school officials, and staff, were established at the onset of the project and were integral to its success.

In collaboration with these stakeholders, the ZNLTP implemented four main activities:

  • Adapted the existing nursing curriculum into e-learning modules and integrated the material into a Learning Management System (LMS).
  • Provided e-learning equipment and tools to schools, hospitals, and students, and designed and implemented life skills and computer literacy trainings for students.
  • Awarded scholarships for the program to 514 disadvantaged students.
  • Developed a new Life Skills curriculum and provided pre-service nurses with training to help build self-confidence, professional behaviour in medical settings, and effective time management.

Curriculum Design

Since the introduction of the ZNLTP, the number of students who have accessed nurse and clinical officer training via e-learning has steadily increased from 134 students in 2014 to 763 students in 2017, with a total of 2,077 e-learning students enrolled to date. In 2017, the first cohort of 92 e-learning students sat for the GNC final examination and achieved a 90 percent pass rate, comparing favourably with the overall exam pass rate of 84 percent.

How the Program Has Evolved

In 2017, the ZNLTP project began exploring the potential to expand the e-learning to train clinical officers in Rural Health Centres. The ZNLTP Life Skills curriculum has since also been used to train over 4,800 registered nurses from private and public schools across Zambia.

During the planning and implementation phases and throughout the project, key stakeholders have continued to meet to discuss and support various project components, including partner school selection and integration of e-learning activities with national health policy.

Stakeholders continued to meet to discuss and support various project components, including school selection and integration of e-learning with national health policy.

Changing Mindsets about E-Learning as a Method to Train Nurses

One of the most important accomplishments of the ZNLTP has been its impact in changing the way key stakeholders, such as MoH officials, GNC officials, school staff, and students, perceive e-learning as a method to train pre-service nurses. These shifted mindsets also appear to be influencing government policy decisions in the nursing sector and the broader health field in Zambia.

The Students

The performance of e-learners and their positive results from exams and lab work have provided concrete evidence of the effectiveness of the program. In addition, the mindset of the in-person program students has also shifted since the inception of the program. There was previously a negative perception of the e-learning program, with some of the in-person students believing that the e-learners would not become nurses, but would become assistant nurses instead. However, after seeing the e-learners studying the same curriculum, learning the clinical component side-by-side with them, and taking the same exams, many of the in-person program learners have changed their minds. Some have said that, now knowing more about e-learning, they would choose that method if they had to make the decision again. E-learners valued the opportunities provided through the e-learning program, including the exposure to technology that they felt would be beneficial to them throughout their careers.

“… from what I have actually observed, the e-learning group, in terms of performance, is better than the regular (in-person) ones. It scores higher than what we see in regular class. I hope it continues just like that.”

- Principal Tutor

“I love the e-learning concept as it is very student-centred. The process allows the students to take charge of the learning process.”

- E-learner

The e-learners themselves report feeling more confident in the e-learning approach and equal to their in-person program colleagues.

The Institutions

Most school officials and school staff now support the use of e-learning to train nurses. They recommend the continuation of e-learning in their schools and the implementation of e-learning programs in those not currently using it. Many school staff support expansion to include in-service and upgrading opportunities, arguing that the expansion will be easier for those upgrading or already working in the industry, as the material and vocabulary are not entirely new to them.

School officials noted that e-learning would reduce the challenge faced by hospitals when nurses go for in-service training, since trainees could continue working while learning remotely. They also described the positive experiences they had with e-learners, noting that on exams and on the wards, the e-learners were performing as well as the in-person students in most cases, and sometimes better. These personal experiences with e-learners and exposure to the training program have helped reduce initial skepticism about the program.

The Ecosystem

There was some initial skepticism about the effectiveness of e-learning for nurse training. There were two primary concerns — that students would not be able to learn the material on their own, and that clinical skills could not be effectively taught remotely. To address these misconceptions, ZNLTP staff and partners prioritized awareness-raising during the planning and implementation phases. This important work was supported by both the former Minister of Health and stakeholders who had personal experiences with e-learning.

Over time, government stakeholders have shifted as they see students successfully complete the training and pass the same theoretical and practical exams as the in-person students. The positive reports by schools and practicum sites have also contributed to the change in mindset. Positive MoH and GNC visits and assessments have also helped reinforce positive perceptions. As one ZNLTP staff member said, “The government is not looking back” when it comes to e-learning.

 

Transforming Policy and Practice in the Health Care Sector

ZNLTP Influence on the Nursing Sector

Because the need for housing had previously restricted student intake, the ZNLTP has increased the number of students that schools can accept each year. It is also reducing the impact of nurse burnout and high demand on the health care system.

As a result, the three schools reviewed for this case study saw a 60 percent increase in student enrollment in 2014, and a combined 48 percent increase in enrollment in the following three years.

The first cohort of e-learners graduated in September 2017. Ninety-two ZNLTP e-learning students took the GNC final examination in May and June of 2017, and 83 (90 percent) passed and will be certified as nurses. An additional 28 nursing students successfully took the GNC final examination in December 2017.

The number of e-learning program graduates is expected to increase to 427 in 2019, and to continue to increase in subsequent years as the project expands to 14 new schools in 2018.

By the time the project closes, it is expected that the ZNLTP e-learning method will have been integrated into 28 nursing and clinical officer schools (out of 60 institutions in Zambia).

In addition to an increased acceptance of the e-learning format, the ZNLTP influenced attitudes toward the importance of life skills training in the development of competent nurses. After an evaluation of the ZNLTP pilot schools in 2014, the GNC found that the Life Skills training component was “performing miracles.” Since then, the GNC has decided to integrate the ZNLTP’s Life Skills training component into the general nursing curriculum across Zambia, making it a required part of any certified nursing school training. The MoH supported this decision, describing the training as a means of providing necessary skills and developing stronger, more resilient students. The Ministry has included the Life Skills training in its new eHealth Strategy 2017–2021.

“It was a bold decision [to support e-learning for pre-service training] as they had not had such a program in the country before.”

- GNC Official

The GNC decided to integrate the ZNLTP’s Life Skills training into the nursing curriculum across Zambia. The Ministry supported this decision, describing its role to develop stronger, more resilient students.

ZNLTP Influence on Zambia’s Health Care Sector

The Zambia National Health Strategy 2011–2015 articulates the country’s desire to build information and communications technology (ICT) capacity. The ZNLTP has successfully leveraged this strategic direction. The influence of the program is now being felt beyond the nursing sector in Zambia, with the introduction of e-learning methods into the MoH National Training Operational Plan 2013–2016.

In April 2017, the MoH announced the launch of its eHealth Strategy 2017–2021. The plan was influenced by the implementation of the ZNLTP as the project provided a concrete example of applied e-learning in action. The plan focuses on increasing the efficiency of the health care system in Zambia via three pillars, one of which is e-learning and the integration of life skills training into the nursing program. It also focuses on ensuring that health services staff are computer literate.

The eHealth Strategic Plan also seeks to increase the use of ICT. One example is SmartCare, a singular electronic health record system for “low resource, disconnected settings.” It replaces hard copy files with an electronic health card that contains an individual’s health history. Private hospitals have already started to implement the SmartCare system and public hospitals are following suit. Computer literacy and familiarity will be required of all nurses once the SmartCare program is fully operationalized. ZNLTP staff view the Strategic Plan as a major success for the project because it sets the stage for a policy environment that embraces and supports utilizing technology in innovative ways.

The influence of the program is being felt beyond the nursing sector in Zambia.

Sustainability: The Future of E-Learning in Zambia’s Nursing Sector

Considerations Moving Forward

The ZNLTP has fostered new avenues for economic participation and youth livelihoods — a source of pride for all the stakeholders involved. From the outset, the ZNLTP has encouraged sustainable outcomes across its program offerings. By providing inclusive and context-specific training informed by a multi-stakeholder approach, the program has provided leadership and life skill development opportunities for health services providers, and has affected change in the broader Zambian health sector. To sustain these advances, supportive policies, initiatives, and strategies are needed to ensure longevity and meet evolving demands.

Eliminate Constraints for Vulnerable Youth

Enrollment Fees

The ZNLTP has demonstrated that e-learning can help address both the challenge of a nursing shortage and youth unemployment in Zambia. The fees associated with schooling, however, mean that nursing training remains inaccessible for many young people. Recognizing this, the ZNLTP made scholarship support one of its priorities, providing 514 disadvantaged students with scholarships (431 full scholarships and 83 partial scholarships).

The MoH provides in-service scholarships to nurses and should strongly consider including pre-service in the MoH scholarship program. The MoH is in talks with the Department of Social Welfare to expand bursaries and loans to nursing school students. The continuous provision of scholarships will provide access to dignified and fulfilling work for disadvantaged youth.

Application Fees

Oftentimes even the application and interview fees required by nursing schools are a barrier for disadvantaged students and can restrict access for many of the most disadvantaged youth. There are a few schools that will waive the application fee, and sometimes even tuition fees, for vulnerable youth, but this is the exception, not the rule. More schools should be encouraged to remove these initial barriers to support the MoH scholarship efforts and open access for the most disadvantaged youth.

Institutional Capacity and Infrastructure to Support E-Learning

Greater emphasis should be placed on a more systematic peer-to-peer, cascade model for training the tutors (i.e., classroom instructors) and support staff. Once trained by ZNLTP staff, tutors become trainers or “master” tutors, and train any school staff who were unable to participate in the original training. They also conduct additional refresher training for those who require it. This approach is viewed as less intimidating for those with limited computer experience, and has been successfully used elsewhere.

This staff training approach may be made more effective with the following considerations:

  • Providing incentives to tutors will help keep them motivated and secure their buy-in.
  • Consideration should be given to balancing opportunities for upgrading and training with tutors' already heavy workload.
  • Because tutors' training needs may differ based on their background or experience, it is important to develop and track the different types of capacity-building activities that are needed.
  • School staff have expressed an interest in engaging across institutions and learning skills and best practices they can then apply to their home schools.
  • Clinical instructors and mentors could be better integrated into the training, since they are also part of the e-learning program; additional training and capacity building could prepare them for the unique facets of engaging with e-learning and new technology.

In relation to technology to support e-learning, a thorough assessment of technological infrastructure should be part of the criteria for school selection for all new e-learning programs, including:

  • The reliability and accessibility of the internet within the region of implementation.
  • The technical specifications of a server system and ensuring that it can handle the expected traffic.
  • Ability to ensure technological compatibility so that e-learners and tutors can access the required learning resources.

To illustrate the final point above, ZNLTP staff had installed computers in the wards of hospitals associated with the ZNLTP nursing schools. However, the team quickly recognized that the computers provided to the schools and placed in the wards were not useful for e-learning students during their self-study period at home. Therefore, the program re-evaluated the situation and decided to provide students with electronic tablets so they could more easily access the e-learning modules.

Build on Progressive Political Alignment to Scale E-Learning

Leveraging the momentum of SMART Zambia — the national government’s e-governance and technology strategy — and the eHealth Strategy, stakeholders have taken some initial steps toward ensuring the sustainability of the ZNLTP post-completion.

The Minister of Health launched the training of e-learners at the Mbala School of Nursing and opened the Kafue Virtual School of Nursing, the first school to offer e-learning exclusively for registered nurse courses. The MoH has also appointed the first Director of Nursing to spearhead all nursing training and practice in Zambia.

With the MoH making several pronouncements in relation to opening more e-learning schools, the project will soon face challenges with regard to managing the demand of these schools, particularly with the provision of tablets and computers. To this end, the project has engaged the MoH and proposed that students in the new e-learning program should start buying their own tablets and computers and that the cost of tablets should be embedded into the students’ school fees. The GNC would procure the tablets and sell them to students at a more affordable price, with a one-year installment option. This collaborative approach will provide youth with access to tablets and enable e-learning to be further embedded into the Zambian education system.

“When we are doing planning each year, they [e-learners] have to be factored in, so I believe that when these students are off the support of the funder, they have to be factored in the budget and the government will be willing to pay for them.”

- MoH Official

Conclusion

The ZNLTP has responded to rising unemployment among youth in Zambia, a lack of job preparedness, and a critical nursing shortage.

These have been addressed by:

  • Increasing the capacity of nurse training institutions to accept more youth into programs.
  • Building nurses' life skills.
  • Shifting mindsets at three levels: ecosystem (MoH), institution (schools, hospitals), and individuals (e-learning nursing students).
  • Securing stakeholder buy-in to support e-learning as a method to train nurses pre-service.
  • Providing youth with access to the formal sector, and the flexibility to learn and earn at the same time.
  • Helping students improve their self-confidence, life skills, job readiness skills, and technological and research skills.

As the first cohort of students that graduated transitions to employment, the ZNLTP will have the opportunity to fully assess the employment rates of the nursing graduates, their skill levels, and their respective employers for the following six to twelve months. The findings from their post-graduation assessments will further evidence the added value of the e-learning pre-service training combined with life skills, computer literacy, and workforce development.

While additional work is needed to enhance the sustainability and continuation of the project post-completion, the MoH has shown increased ownership and adopted a strategic plan to support e-learning and life skills training while identifying public-private partnerships. This initial step highlights the influence that the ZNLTP has had on policy, which is one of the greatest strengths of the program, in addition to its success in collaborating with stakeholders across governmental, institutional, and individual levels.