The Need for Student Learning Centers for Family Planning Education in Nepal

Nurses are key providers of non-permanent family planning methods in Nepal. A needs assessment of family planning training for nursing students in Nepal revealed that more clinical simulation practice was needed to prepare students for family planning service delivery and that humanistic anatomical models were underutilized in lab practice settings. A Nursing Advisory Group comprised of Nepalese Nursing leaders and nursing campus chiefs in conjunction with Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) recommended that preservice training, specifically clinical simulation practice for family planning service delivery, be strengthened. In response to the low use of anatomical models, and the desire for students to be well-skilled prior to entering the clinical setting, an agenda was agreed upon. Based on Social Learning Theory, the development of a special program to implement the creation and use of family planning simulation labs in Nepal‘s major nursing schools, to be called Student Learning Centers (SLCs), was developed. Family planning instructors, nursing campus chiefs (a title comparable to dean), Masters prepared Nepalese nurses, staff, and U.S. nurse consultants employed by JHPIEGO worked together on the development and implementation of this project.

The Need for Family Planning in Nepal

Nepal, a mountainous country landlocked between India and Tibet, is home to 24 million people and eight of the world‘s ten highest mountains. In 1997, the per capita gross domestic product was $1,090.00, one of the lowest in South Asia, and the total fertility rate (TFR) was 4.5 (Knowles, 2000). In 1995, the proportion of people with income below one dollar per day was 50%, and the adult literacy rate was 28% (Knowles, 2000). Gender inequalities are evidenced by the disparity in the literacy rate among men (51.8%), and women (18%) (Ogilvie, 1998). In 1996, 28% of the people in Nepal reported using some modern contraceptive method, which is a sharp rise from only 3% reporting modern contraceptive use in 1976 (Ministry of Health, Nepal, 1996). Female sterilization is the most common method of contraception in Nepal where permanent methods made up 72% of contraceptive use in 1994 and 1999 (Stash, 1999). However, from 1976 to 1996, the use rates of temporary contraceptive methods for spacing births increased from 1% to 9% among recently married, non-pregnant women (Thapa & Friedman, 1998). Among people using temporary contraceptive methods in 1999, 56% used Depo-Provera, 23% used condoms, 17% used oral contraceptives, 1.7% used the IUD, and 1.5% used Norplant (Ministry of Health, Nepal 1996). Oral contraceptives are perceived by many Nepalese women to carry unacceptable health risks, which could have negative health effects and limit productivity, a factor that appears to limit the use of oral contraceptives (Stash, 1999). Unmet need for contraception among currently married women in Nepal aged 15 to 49 was estimated to be 30% in 1995 (Stash, 1999).

Nursing‘s Role in Family Planning

Nurses are key health workers needed to reach Nepali goals of women‘s reproductive health and widespread use of contraception to increase the amount of time between births and to contribute to a lowering of the total fertility rate.

More emphasis is recommended on temporary family planning methods which can be used to space the timing of births...

More emphasis is recommended on temporary family planning methods which can be used to space the timing of births as contrasted to permanent methods such as female or male sterilization, which are generally employed after a certain family size or number of sons born has been reached. The decision to limit family size is determined by the number of sons, because a preference for sons still exists in Nepal, as in many countries where males command more power within society than females (Stash, 1999, Thapa, 1989). Nurses in Nepal are responsible for family planning counseling and the delivery of temporary methods such as the Depo-Provera contraceptive injectable, oral contraceptives, and condoms.

Nurses also often coordinate family planning services and supervise auxiliary nurse midwives and other community health workers in the dispensation of family planning supplies. (Auxiliary nurse midwives are not nurses, but graduates of a two-year program focused primarily on midwifery, which enables them to assist in maternity wards in hospitals or in rural areas where medical personnel are scarce. The position of auxiliary nurse midwife is not the equivalent of the Certified Nurse Midwife in the West and currently there is not an advanced degree program for Nurse Midwifery in Nepal.) Nurses who have completed special additional training insert Inter-Uterine Devices (IUDs) and Norplant as well as assist physicians in voluntary sterilization procedures. Women are the preferred providers of IUDs and it is predicted that if more female providers, including nurses, were trained in IUD insertion and management, IUDs would be used by more Nepalese women (JHPIEGO, 1993).

Nursing Education in Nepal

The first school of nursing opened in Nepal in 1956, and now there are seven nursing schools (Ogilvie, 1998). Currently, three programs for nursing preparation are available in Nepal. The first is the initial Program for Certificated Licensed Nurses (PCLN), which takes three years and is the practice level of most nurses in Nepal. The PCLN program focuses on basic nursing skills development. Subsequently, a Bachelor of Nursing (BN) program is available to PCLN graduates who have practiced for three years or more. The BN program builds on basic skills to focus on management and teaching skills. There is one Master‘s of Nursing program in Nepal at Tribhuvan University in Kathmandu. In addition, several master‘s prepared Nepali nurses have obtained their advanced degrees from programs outside the country or in affiliation with universities outside Nepal.

The research of Anderson, Nichol, Shrestha, and Singh, conducted in 1988, indicated that Nepalese nursing instructors wanted an increase in clinical practice and training time for students for a full range of nursing activities, including family planning. A more recent needs assessment by the Nursing Advisory Group (JHPIEGO, 1993) found that additional curricular activity was needed to build in preservice education and practice in family planning. The term preservice education refers to training that takes place during nursing school, in contrast to in-service education, which refers to training for nurses when they already have their degrees and are practicing in a healthcare setting. Preservice training is the preferred method of education because it can be tailored to fit in to nationally accepted service guidelines, reaches more people, is less disruptive to the service delivery system, and is less costly than in-service training. Recommendations were made by nursing leaders within Nepal in cooperation with JHPIEGO that family planning and reproductive health training be strengthened in both the nursing classroom and clinical lab setting, both preservice venues (JHPIEGO, 2000).

Nursing students‘ state that one of their major sources of stress is being reprimanded by nursing instructors when they are in the clinical setting (Anderson et al., 1988; Mahat, 1996). Student Learning Centers (SLCs) can help students and faculty better prepare for hands-on clinical work through guided instruction and practice, and can potentially alleviate some of the stress of being a new or student nurse as well as prepare both the instructors and students with established goals of clinical practice standards.

The purpose of the SLCs is to provide a sustainable forum for preservice training of student nurses to enhance family planning services delivery over time that will meet local goals of increasing utilization of temporary or birth-spacing methods in concert with the overall strengthening of comprehensive reproductive health services. It is a recognized goal of the Nepal nursing community to have more women trained as expert nurses ready to be the trusted providers of family planning services for birth spacing.

Establishment of a Student Learning Center

The following sections outline the steps followed to establish the SLC at Maharjgunj Nursing Campus at Tribhuvan University. Implementation of a SCL at this particular campus is described because it sits in Kathmandu, the capitol and most cosmopolitan urban center in Nepal, and is a leader for all other nursing campuses in the country. It is also associated with a major teaching hospital and The Institute of Medicine. The author participated in the implementation of the SLC at this site. Nepalese and U.S. nursing experts did thorough groundwork for the project, meeting and planning over a number of months. The physical manifestation of the project took place over a ten-day span in March of 2000.

Meeting with Family Planning Nursing Teachers and Nursing Campus Chief

Family planning education was part of the lecture content of the nursing curriculum but had limited, if any, student practice time associated with the classroom instruction. The existing family planning and reproductive health training equipment and lab facilities at Maharjgunj Nursing Campus in March of 2000 consisted of two humanistic pelvic models, a practice arm for injectables and a smattering of gynecological exam tools such as speculums. However, the equipment was kept locked in cabinets in a supply room housing all the other nursing clinical lab equipment. The room was off limits to students during non-lab hours and there was no system in place to allow or encourage clinical practice with anatomical models without the supervision of an instructor. Instructors were already extremely busy with heavy teaching loads and clinical site supervision responsibilities and therefore not available to supervise additional lab practice in family planning and reproductive health. These factors were recognized as limiting to student‘s practice time by the campus chief and the family planning instructors.

The professional nursing faculty was eager to figure out new ways of allowing students access to the equipment and practice time, but as in many other hierarchical systems, power was somewhat entrenched in the status quo.

The issue of access to the equipment was of grave concern as historically, whomever held the key to the locked room held power over access and lab practice time. The professional nursing faculty was eager to figure out new ways of allowing students access to the equipment and practice time, but as in many other hierarchical systems, power was somewhat entrenched in the status quo.

Agreement about the shape and purpose of the SLC was reached during preliminary meetings with the family planning instructors, campus chiefs, and JHPIEGO nurses (M. E. Lapp, personal communication, October 18, 2000). The groundwork was set for the establishment of the permanent family planning student learning center (SLC). Social Learning Theory was used to design the teaching protocols for the hands-on practice and explanation of the use of anatomical models. How contraception was theorized and taught in the lecture classroom was not addressed by this project. It was decided that the SLC should be set up in the large area at the back of the main lecture hall used by the family planning instructors. The contribution of humanistic anatomical models by JHPIEGO consisted of:

1. 4 Zoë® realistic pelvic models with changeable cervixes and uteri
2. 2 full chest breast exam models with naturalistic feeling breast tissue and realistic abnormalities
3. 2 realistic penile models and condoms for demonstration and practice
4. 3 practice arms for Depo-Provera injections
5. 1 Norplant practice arm and insertion and removal kit
6. 2 complete IUD practice insertion kits

The practice models are stationed on tables with laminated practice checklists detailing the steps involved in breast exams, pelvic exams, condom use demonstrations, and Depo injections, as well as all the necessary practice equipment.

Modeling Lab Use

The U.S. nursing consultants reviewed with the family planning teachers the concepts of humanistic model usage, learning guide and checklist usage, and positive coaching/teaching skills. Using Social Learning Theory as guide, ideal lab practice techniques were demonstrated for each model. This teaching style, which is practiced in many American nursing schools, involves two people working as a team. One person reads the exam checklist and guides the session as their lab partner actually practices the exam steps on the anatomical model. The students then trade places so each gets to practice both the examination and the coaching. Positive reinforcement for appropriate technique is freely given to the person practicing on the model, as well as gentle non-reprimanding constructive criticism. This teaching style works well to foster confidence and competency in both coaching guidance and clinical practice skills.

The Nepalese family planning instructors quickly adopted this style of demonstration and return demonstration teaching.

Emphasizing the power of positive reinforcement and praise may help to alleviate some stress described by Nepalese nursing students...

Soon they were proficient in the use of all the models and incorporated the positive reinforcement techniques into their own presentations. Emphasizing the power of positive reinforcement and praise may help to alleviate some stress described by Nepalese nursing students of fear of being harshly criticized by teachers in clinical settings.

Introduction of the SLC to all Nursing Instructors

To build campus support for the SLC as a permanent fixture in the back of a main lecture hall, a grand opening of the lab was held. Nursing instructors from all disciplines attended a luncheon and official opening of the center. The campus chief as well as JHPIEGO representatives gave support as the family planning instructors gave speeches explaining the importance of the student learning center in their teaching efforts. The main family planning instructors then demonstrated the ideal model usage and taught all the nursing instructors how to use the models and checklists. A roundtable discussion was facilitated to hear from all the instructors and secure support for full student access to the practice area and models. A great deal of status within the school was associated with the successful implementation of this project and with the full support of the campus chief, the family planning teachers were given institutional power to carry out their goals. Cultivating and nurturing such valuable institutional support is considered essential for the implementation and maintenance of projects like this, and we were fortunate to be working with visionary nursing professionals that are devoted to expanding the nursing roles by strengthening the knowledge base.

Introduction of the SLC to Students

After thorough preparation and planning, the SLC was at last introduced to the nursing students. Seventy second year student nurses rotated through the SLC in two groups. Each group was given a didactic presentation co-taught by the Nepalese family planning instructors and the JHPIEGO consultants. As in the previously described demonstrations, each teacher-pair modeled use of the SLC by working as a team with one person reading the examination checklist, and the other practicing the described technique, such as breast or pelvic exam. After demonstration of correct usage of all the models, students paired up and practiced on each and every model. See photographs of the nursing students practicing in the SLC (see below). The students were very bright and enthusiastic and reported they enjoyed the lab very much, especially the pelvic exam practice, which was new to them. Teachers were stationed at every table to help with any questions and guide technique; and the students return demonstrated all the positive coaching and learning techniques that work so well to reinforce learning. Students reported that the checklists and guides were helpful for practice as was the team approach. At first there was some concern that the condom models would be too embarrassing for the students or the teachers to work with, but all were able to overcome any discomforts and practiced in a completely professional manner, using gentle humor to dispel anxiety.

Evaluation and Follow-Up

Nine months later, the SLC was still in place, having the models covered with sheets when not in use. Free access is permitted for student practice.

Timely reinforcement of the overall reproductive health initiative will be helpful as it is all too easy to fall back into patterns of practicing only things like Depo injections.

In order to fully evaluate the effects of the SLC on family planning service delivery, an evaluation plan is being implemented to assess student usage of the SLC via a log-book sign-up for times the lab is being used. Recommendations have been made to include a lab exam in the family planning curriculum that will check off students on practice skills in the SLC as well as the clinical setting. Timely reinforcement of the overall reproductive health initiative will be helpful as it is all too easy to fall back into patterns of practicing only things like Depo injections.

Periodic refresher visits from JHPIEGO staff can help build regular SLC usage into the curriculum and make it easier for the family planning instructors to do their job. All seven nursing campuses in Nepal are scheduled to participate in the program, which has been implemented thus far at three nursing schools. In the long term it will be necessary to evaluate whether nursing graduates exposed to the SLCs are better prepared and proficient in family planning service delivery. Nursing continues to grow as a profession in Nepal and nursing‘s involvement in family planning and reproductive health is vital to improving the health of all people in Nepal.

Author

Suzanne I. Knecht, BA, BSN, MSN, PhDc
E-mail: sik@umich.edu

Suzanne Knecht is a doctoral candidate in Women‘s Health at the University of Michigan School of Nursing with a special focus on international family planning. Her work as a Women‘s Health Nurse Practitioner at public and low-cost clinics specializing in family planning and STD prevention, combined with a lifetime of travel, has prepared her to practice nursing in international settings. Her involvement in international nursing was generously supported by a new initiative from the School of Nursing‘s office of international affairs. Special thanks are offered to Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), and the U.S. and Nepalese nurses working to advance nursing and women‘s health in Nepal.

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