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Running head: TANZANIAN SURVEY ANALYSIS 1

Dixie State University and Tanzanian Educational Exchange Program

an Analysis of Participation Surveys

Erica Bailey

Dixie State University

TANZANIAN SURVEY ANALYSIS 2

Tanzanian Survey Analysis

Tanzania, is a large, east African country with a population of 47 million people.

When a student graduates from a nursing school at university in Tanzania, they are not

only trained with the equivalent of the RN degree, but they are midwife trained as well!

A report commissioned by Democratic and Health Surveys reports that 67% of all urban

childbirths are carried out by an RN/midwife (DHS, 2009). 10 nurses came to the

United States with a goal, to learn from our skilled nurses about safe maternal and

neonatal care, return to Tanzania, and mentor other nurses there on the skills they have

learned. This paper is an analysis of two surveys given to these participants, one

before the beginning of a simulation exercise and the other at the end of their training

experience.

Pre Simulation Survey

Introduction

The questions contained in the following section, represent those asked on the

survey that was given to the participants at their first simulation day at Dixie Regional

Medical Center in St. George, UT.

Question 1

The first question of the survey

established the experience level of the

visiting nurses. With all of the nurses

having at least five years of experience,

this is a knowledgeable group!

Question 11

6

3

1

Years of Nursing Experiencen = 10

1-4 years5-9 Years10-15 yearsMore than 16

Figure 1. Question 1 of pre-simulation survey. Years of Nursing Experience.

TANZANIAN SURVEY RESULTS 3

It was important to establish the

participant’s level of comfort in dealing

with childbirth situations. This

question addressed the majority of

childbirths, which many participants

described as occurring 80% of the

time. As trained midwives I would

expect this number to be exactly

where it is, with 100% of the respondents reporting they agree or strongly agree that

they are comfortable with most childbirth situations.

Question 12

This too is a question to establish a baseline with regards to the care of the

newborn child. As with the previous

question, this shows all of the

Tanzanian nurses feel proficient with

regards to newborn care; although

compared with the previous question,

at least one nurse is more comfortable

with newborn care than childbirth

situations.

Question 13

4

6

I Am Comfortable In Most Childbirth Situations

n=10

Strongly Agree (5)Agree (4)Neutral (3)Disagree (2)Strongly Disagree (1)

6

4

I Am Comfortable In Caring For Newborns

n=10


Figure 2. Question 11 of pre-simulation survey. Childbirth Situations.

Figure 3. Question 12 of pre-simulation survey. Newborn care.


The results of this question, show that the nurses have the same level of

confidence with post-partum care as

they do with laboring and newborn

care. All of the respondents

reported that they agreed or

strongly agreed that they were

comfortable in caring for the post-

partum woman.

Post Simulation Survey

Introduction

The questions contained in the following section, represent questions that were

asked of the Tanzanian nurses at the conclusion of their experiences in St. George.

The focus of this group of questions was to gauge effectiveness of the program, and the

information they were presented.

Question 1

6

4

I Am Comfortable In Caring For The Post-Partum Woman

n=10


Figure 4. Question 13 of pre-simulation survey. Post-partum care.


One of the challenge of a

program such as this is presenting

the necessary information in such a

way that is not hindered by cultural

or language barriers. One

additional obstacle that we had to

overcome was the differences in two

completely different health care

systems. The equipment and supplies that we take for granted here in the United

States, are not always readily available in Tanzania. This program was structured with

these obstacles in mind, so with regards to the survey, it was very important that we

gauge if we were successful in relaying skills and competencies that would translate

once the nurses were back in their home country.

It would appear from the results from this question that we obtained successful

delivery of the message in a relatable and transferrable way.

Question 6

As the focus of this capstone,

assessing the simulation facilities

was an important question to ask.

The results show that the simulation

facilities at the “400 East” campus of

10

The Simulation Facilities Were Ad-equaten=10


9

1

I Feel LIke The Competencies and Skills I Was Taught Can Be Applied To My Nurs-

ing Practice Back Homen=10


Figure 5. Question 1 of post-simulation survey. Program application in Tanzania.

Figure 6. Question 6 of post-simulation survey. Simulation facilities.


Dixie Regional Medical Center were perceived as adequate by 100% of program

participants.

Question 8

On the day of simulation, there were lectures presented by two physicians. One

lecture was labor and delivery and

the other on newborn care including

emergency situations. Both lectures

were a combination of PowerPoint

presentation, lecture with some

hands on elements. It was

extremely important to assess if this

message was understood by the

participants of the simulation as it

directly related to the situations that would be covered in the simulations.

From the survey responses, it appears that we might have gotten off track here.

The doctor’s message does not appear to have connected with half of our participants.

Question 9

Despite the communication

problems that existed with the

physicians, it appears that the

nurses who were utilized were able

to connect with the Tanzanian

nurses on a level they understood.

7

3

The Simulation Nurses Spoke To Me In A Way that I Understood

n=10


42

2

2

The Simulation Doctors Spoke To Me In A Way that I Understood

n=10


Figure 7. Question 8 of post-simulation survey. Physician Understanding

Figure 8. Question 9 of post-simulation survey. Nurse Understanding.


Question 10

The cornerstone of this whole endeavor has been to teach these visiting nurses

skills that they would be able to learn, take back to Tanzania and then teach other

nurses the information they learned in the United States. The goal of this whole

program was derived from the Tanzania Global Health Initiative Strategy ("TGHIS,"

2011) which is to improve the health of all Tanzanians, and especially the health of the

most vulnerable groups of women, girls, newborns, and children under the age of five

("TGHIS," 2011, p. 11). The simulation portion of this education was designed with

these goals in mind. In addition, the simulation was intended to contain training that

could be replicated back in Tanzania;

therefore, this question evaluated the

whole simulation program

effectiveness. Based on the survey

responses, it would appear that the

simulation education was presented in

a way, where the competencies

learned could be used at home.

Question 16

8

2

Simulation Taught Me Skills That I Can Use In My Nursing Practice

n=10


Figure 9. Question 10 of post-simulation survey. Simulation Effectiveness.


There was a clinical

portion to the Tanzanian Nurses

that would allow these nurses to

“shadow” Dixie Regional

Medical Center staff nurses, in

an effort for the vising nurses to

gain some real-life, hands on

training. There was some concern

about this component as it was unclear if the care provided would be able to be

replicated and repeated in Tanzania. On the whole it appears that the participants

thought their clinical experience had some probative value, with 80% of respondents

reporting their satisfaction with clinical rotations.

Comparison of Surveys

Introduction

The following few questions were asked at the beginning of the Tanzanian

nurses program and again at the end to evaluate personal feelings on their personal

experiences.

Questions 2

The initial survey question was asked “I have felt welcome”, and at the final

survey it was worded “I have been made to feel welcome throughout my stay”. From

the survey results it appears that overwhelming, they felt welcome in the beginning, but

as time wore on, these feeling dissipated. No further questions were asked to further

ascertain the source of these feelings.

Figure 10. Question 16 of post-simulation survey. Clinical Rotation Effectiveness.

4

4

11

Clinical Rotations Taught Me Skills That I Can Use In My Nursing Practice

n=10



Questions 10/15

The participants were asked

about their opinions with regards to if “clinical experience is an effective method of

education. The data shows that before the clinical rotations began, the nurses believed

highly in the value of clinical experience; however after all of the individual shifts were

over, that their opinion of clinicals being a great way to learn dropped sharply, from 90%

pre-clinical selecting top-box to only 50% at the end. For some reason, it appears we

did not live up to the participant’s expectations with regards to the clinical experiences.

The free text survey answers later in this

document, might hold some clues for the

source of the dissatisfaction,

Questions 9/4

Strongly Agree (5)

Agree (4) Neutral (3) Disagree (2) Strongly Disagree (1)

0

2

4

6

8

10

1210

0 0 0 0

4

2

4

0 0

I Was Made To Feel Welcome Throughout My Stayn=10

Pre Simulation Survey

Post Simulation Survey

Num

ber o

f Res

pons

es

Figure 12. Question 10 on pre survey & Question 15 on post-simulation survey. Clinical Effectiveness

Strongly Agree (5) Agree (4)0123456789

10 9

1

5 5

I Think That Clinical Experience Is A Great Way to Learnn=10

Before Clinicals After Clinicals


Just as we evaluated the opinion

of the clinical experience in the question

above, overwhelmingly, 90% of the

respondents felt pre-simulation that

simulation was an effective method and

surprisingly, these numbers held when

we did the final survey. Meaning, at the

conclusion of the program, simulation

met the expectations of the

participants with regards to the educational value of simulation.

Simulation and Clinical Program Evaluation

Introduction

In order to evaluate the overall effectiveness of the Dixie Regional Medical

Center Simulation and clinical experience, it was important to survey opinions on a

particular topic before (to obtain a baseline) and after the program. Four specific,

possibly emergent, scenarios were selected to be taught during simulation, with idea

being that the visiting nurse would be exposed to the same situation during hands-on

clinical shadowing. The following graphs illustrate the survey responses to the same

four childbirth situations before the program began, after simulation and again after

clinicals.

Questions 14/12/18

The Tanzanian nurses were asked about their level of comfort in dealing with

these situations involving shoulder dystocia.

Figure 13. Question 9 on pre survey & Question 4 on post-simulation survey. Clinical Effectiveness

Strongly Agree (5) Agree (4)0123456789

10 9

1

9

1

I Think That Simulation Is A Great Way to Learnn=10

Before Simulation After Simulation


Before education began only 40% stated that they “strongly agreed” that they

were comfortable with dealing with this situation. After simulation this number rose to

60% strongly agree. There was not as much agreement about dealing with this

situation “because of clinical experience”, strongly agree was only 20%, possibly

because of the unlikelihood of this situation appearing in the clinical setting the day they

were there.

Question 15/13/19

Strongly Agree (5)


0

1

2

3

4

5

6

7

4

3

2

0

1

6

2 2

0

2

6

1

0

1

Comfort Managing Situations Involving Shoulder Dystocian=10

Before Simulation

After Simulation

After Clinical

Num

ber o

f Res

pons

es


At first glance, those who “strongly agreed” with the questions regarding

confidence managing maternal respiratory problems dramatically increased after

simulation. During the first survey, the nurses reported that 80% of them either strongly

agreed or agreed with the question about managing maternal respiratory problems;

interestingly enough, after clinicals that the number of respondents selecting the top two

boxes drops to 60%. It is impossible to know at this point what this drop is attributed to,

possibly seeing how this situation is managed is so different from how they are able to

replicate this in Tanzania.

Questions 16/14/20

While not a dramatic increase, this question has the most definitive proof of the

efficacy of simulation during this program. With regards to dealing with newborn

respiratory problems, the before survey and the after clinical responses were exactly the

same; however when asked “Because of simulations, I am comfortable dealing with

newborn respiratory problems”, there was a 20% increase in those who answered

strongly agree.

Strongly Agree (5)


0

1

2

3

4

5

6

7

8

3

5

1 1

0

7

2

0 0

11

5

2

1 1

Comfort Managing Situations Involving Maternal Respiratory Problems

n=10

Before Simulation

After Simulation

After Clinical

Num

ber o

f Res

pons

es

Figure 16. Question 16 on the pre survey & Questions 14 and 20 on the post survey. Caregiver Confidence in Dealing with Newborn Respiratory Problems.

Figure 15. Question 15 on the pre survey & Questions 13 and 19 on the post survey. Caregiver Confidence in Dealing with Maternal Respiratory Problems.


Questions 17/11/17

Strongly Agree (5)


0

1

2

3

4

5

6

7

8

9

6

3

1

0 0

8

2

0 0 0

6

3

1

0 0

Comfort Managing Situations Involving Newborn Respiratory Problems

n=10

Before Simulation

After Simulation

After Clinical

Num

ber o

f Res

pons

es


The final scenario evaluated during simulation was post-partum hemorrhage.

More than any other specific topic covered, this simulation seemed to have the most

impact on the Tanzanian nurses. Before simulation, the participants only reported that

20% felt strongly that they were comfortable with dealing with post-partum hemorrhage.

For the first time in this survey, 50% of the responses were neutral or on the negative

side of agreeing. After simulation 100% of the nurses selected top two boxes.

Similarly, the clinical experience allowed for 90% to be in the top two selections.

Free Text Responses at the End of Post Survey

At the end of the survey, there were several, fill-in-the-blank type questions.

These were asked to gain some insight into deeper thoughts about the program and

experience. It should be noted that the responses were transcribed here exactly as the

responder answered the questions, even if grammatical or spelling errors exist. The

Strongly Agree (5)


0

1

2

3

4

5

6

7

8

9

2 2

3

2

1

8

2

0 0 0

3

6

1

0 0

Comfort Managing Situations Involving Post Partum Hem-orrhage

n=10

Before Simulation

After Simulation

After Clinical

Num

ber o

f Res

pons

es

Figure 17. Question 17 on the pre survey & Questions 11 and 17 on the post survey. Caregiver Confidence in Dealing with Post-Partum Hemorrhage.


number next to each response indicates the survey number, so, for example, response

number six from each question were from responses from the same visiting nurse.

The most beneficial unit I visited and Why?1) Labor and Delivery because it enabled me to learn different ways of

managing labor with epidural and natural labor2) Labour ward because 1st like to care pregnancy women during

labour3) Labour and delivery people are willing to teach and helpful4) SWUPHD5) NICU – nurses are very competence and ready to share knowledge6) Public Health Department7) The most beneficial unit I visited was labour and delivery; it was

great seeing how epidural used8) Labour ward. Nurse Kristen! Kristen was supportive and ready to

teach me everything.9) All the units I visited were beneficial to me like M/B, NICU, LW and

pediatric care10) OR – I have observed how the coordination and organization is

The least beneficial unit I visited and Why?1) None. All were beneficial to me2) No response3) Simulation because we do not have in our unit4) Managing a pregnant woman in labour and delivery5) No response6) Labor ward and I stayed a day7) The least beneficial unit I visited was public health; I had a few days

out there to catch up everything on time.8) No response9) Public health department10) No response

My favorite portion of my experience has been:1) Simulation portion as it has made me learn more in a real situation

with PRONTO assessment2) Simulation3) Mother, baby and NICU4) Management and prevention of bleeding. Visited water, pools and

waste water plant. Emergency and response time exercise5) Labour and delivery6) No response7) Good and enjoyable because I met new people with different

approach and interaction then I compare with what am used to do at my work place


8) Simulation class at the Dixie hospital; Simulation practice at Salt Lake

9) Salt Lake University and NICU and LW10) Operating room organization

I gained the most nursing knowledge about:1) Knowledge mostly gain was how to manage emergency obstetric

care2) How to care obstetric emergency3) Mother, labour and delivery4) Health promotion, pre and post-natal care, obstetric, newborn and

pediatric emergency.5) Saving life of fetus with respiratory problems and saving woman

during emergency, eg. PPH6) Managing PPH7) Caring of newborn, maternal; children and the things which

decrease maternal and newborn mortality8) Managing obstetric emergencies; neonatal resuscitation.9) PRONTO10) Patient vs. Nurse relationship

I wish they would have taught me about:1) How to manage neonate with surgeries2) No response3) Version, force labor4) Real delivery of a woman5) Post op care6) No response7) I wish they would have taught me on the resuscitation of mother,

because we only did neonatal/newborn resuscitation.8) No response9) No response10) No response

If I could change one thing about this experience:1) Nothing to change but simulation will be given high priority2) I will increase knowledge of managing obstetric emergency3) Nurses must be allow to assist mother during delivery4) Nurses on labour ward should know how to use fetoscope5) No response6) No response7) If I wish I could change this experience; l I would need more weeks

to do so8) I would increase time of experience in simulation at Salt Lake9) No response10) Been taught more with equipment I have in my district


Additional comments:1) The simulation parts is the best way of teaching as it enhances

experience seeing and doing is the best learning2) For the inclinical area to the some nurse to instruct the procedure

first to the new group later rather than doing without explanation3) Living with one meal at hostel was hard for me but God is helpful to

us. Staffs and clinical instructor are very good in providing skills and knowledge. Thank you for allowing us to come at your hospital.

4) Involvement in attending women in labour and delivery as we are midwives!!

5) Simulation is the best way of teaching therefore big up and make it happen in other’s countries where MMR is high.

6) The training was Fantastic. We have been starving by eating bread cause the scholarship was little 1200 USD for seven weeks

7) Next time you should give us more time to practise in all area pertain NICU, mother and baby and labour ward. Too many women labouring on their backs.

8) Simulation is the best way for training. I enjoyed very much Salt Lake learning experience. The facilitators were warm, cooperative and knowledgeable.

9) Nurses should teach the nursing mothers about good position and attachments on breast feeding. What I observe, mothers doesn’t know how to hold their babies during breast feeding.

10) US nurses should have time to conduct deliveries by themselves, rather than doctors. Let the doctors be involved in the case if there are complications of which can not be managed by the nurses.

Obstacles and Limitations of Surveys

While much research was completed by the author of this analysis to ensure an

unbiased, culturally neutral survey, there is always the possibility of a language barrier

when working with those from a foreign country. While the participants spoke very good

English, it is impossible to evaluate, in this setting, reading skills or the understood

meaning of the words.

In hindsight, with regards to some of the questions about specific skills, I wish I

would have used a different measuring scale. I utilized the “Strongly Agree” to “Strongly


Disagree” continuum, and I wish I would have measured achievement with a scale such

as “Expert” to “Novice” across a 5 point gauge.

I would have added another survey at the end of the simulation day, so we could

have measured the responses when the information was fresh. Due to time constraints,

I elected to survey simulation and clinicals at the end.

I would have asked for more allotted time to conduct my surveys so that, after

each question there was a blank area for the participant to expand on the reasons they

selected the choices they did, as it is impossible to ascertain which portion of their

experience lead to the scores they gave. I also think a personal interview could have

been helpful.

The clinical experience is a variable entity, as no two shifts are the same. One

respondent may have rated the clinical experience high with regards to shoulder

dystocia as they were able to see that during their time in labor and delivery; while

another nurse working a different part of the floor would not get that experience. The

variation in the clinical experience could very well could have influenced the survey

results. While it is impossible to stage a clinical experience with the appropriate

training, increasing the number of days at each unit may have leveled out the variations.

Because in clinicals the Tanzanian nurse would have “shadowed” a nurse from

Dixie Regional Medical Center, there is great variation in the experience due to abilities,

level of engagement and interest level of the Dixie Regional Employee. This

employee’s attitude and teaching style would weight greatly on the experience of the

visiting nurse.


Even though we asked the nurses to only evaluate their experiences at Dixie

Regional Medical Center with regards to simulation, the fact remains that they also

attended simulation at the University of Utah, and their feelings about that experience

may have influenced the outcome of this survey.

Recommendations

The first recommendation I would make is to provide time for the Tanzanian

nurses to provide some education for the appropriate nurses at Dixie Regional Medical

Center. We knew going into this that we would have to teach them without the benefit

of electronic fetal monitoring, as it is not widely available in Tanzania; however we

missed an opportunity for them to teach us how to use the fetoscope to monitor the

fetus in-utero. Some of the nurses made a statement to me how “we depend too much

on technology, what if the power went out, how would we monitor labor”? Also in the

free answer section of the survey one respondent commented that our breastfeeding

mothers were holding the babies wrong, another mentioned how many of our mothers

labor while on their backs. They could have educated us on labor positions and breast

feeding holds. With the average Tanzanian nurse in this exchange having almost ten

years of experience, we missed an opportunity for them to share some of their

knowledge in a classroom setting.

Based on the survey results, we missed the mark with regards to the physician

lectures we provided. I sat in on both lectures, and they both seem geared more

towards physicians rather than nurses (or midwives as in this case). The PowerPoints

were recycled from other lectures the physicians had given, and did not take into


account the equipment and supplies these nurse have access to, nor the exact program

goals or simulation scenarios.

Based on the responses from the open answer section, Dixie Regional could

provide a meal for the visiting nurses on the days where they are in clinicals on campus

as a way to help their scholarship money go a little farther.

Looking at the syllabus provided to me showing the timeline of events for this

program, the Dixie Regional portion of simulation was one day compared with five days

of simulation at the University of Utah. Perhaps our simulation time could be expanded

to accommodate more time on each subject, more topics covered and more hands on

training for the participants.

If possible in the future, I would bring into this process a Bachelors of Nursing

Capstone student earlier into the planning. Even though, I was able to start working on

this, through my preceptor, the second week of the semester, I would have enjoyed

being able to plan more of this on the front end.

This was said a couple of times in the survey, the participants would have

enjoyed more time on some of the units; specifically labor and delivery and NICU.

More than once, I was told by the nurses that they would have preferred to visit

when it was not so hot here.

When speaking to the nurses about their experiences, one common theme kept

coming up, the simulation they received at the University of Utah. According to their

website…

PRONTO [International] (2015) was born in response to the WHO

Millennium Development Goals (MDG) 4 and 5 and a call from the Mexican


government to develop a program that focuses on improving the quality of care

for women and neonates during obstetric emergencies.

PRONTO International aims to optimize care during birth. We develop and

implement innovative training strategies that act as a catalyst for health care

providers to make individual, team, and systems changes.

It is easy, in 21st century United States to get caught up in the desire for the newest

gadget, the fastest results, and the next big thing. Pronto International is making the

simulation that we take for granted in this day and age, and taking it back a few steps.

This is a low tech, low fidelity simulator using an “actor” who wears PartoPants, which

are no more than surgical scrubs modified with childbirth components such as an

injection pad for injections, a fake vagina to simulate childbirth, a bag to hold fake blood

and the ability for the actor to push the baby out (of fake vagina) with their hands.

Pronto International focuses their efforts on areas where higher-tech simulators

are not available, usually third-world countries. According to their website, after a trial in

an area of Mexico, they had a 44% decrease in risk for neonatal mortality and a 21%

decrease in cesarean deliveries ("Evidence," n.d.).

While I could not find data comparing this type of low fidelity to our SimWoman,

for the purposes of this survey analysis and recommendations, it might be said that the

Tanzanian nurses might have responded (or possibly did respond) better to this low

tech option; in addition, this type of simulation is more reproducible in their home

country with the low cost kit, and appropriate training.


With that being said, without a doubt, our SimWoman provided the more realistic

scenario for them to learn, and as mentioned before, might have had increased benefits

with smaller group sizes and more time.

Conclusion

According to UNICEF (n.d.), in Tanzania, 45 mothers (out of 10,000) do not

survive childbirth, compared with 28:10,000 in the United States. Ten Tanzanian

nurses traveled 10,000 miles and spent seven weeks trying to accomplish an amazing

goal… to decrease maternal and neonatal demise in their home country. Hopefully, we

equipped them with the knowledge of how to increase the health and well-being of this

at risk population. The surveys given to these nurses paint the picture of a group of

individuals who were pleased with the training they received and they can mentor other

nurses in Tanzania about the skills and proficiencies they learned during their time at

Dixie Regional Medical Center and Dixie State University. They sat through many

lectures, watched demonstrations, participated in simulations, even went hands on with

real patients in the clinical setting, and while it may take years, if not decades, to see if

programs like this one are successful, the innovative Tanzanian Nurses Educational

Experience opened a door to allow for communication, cooperation education and

nursing development to between our two countries. Journalist Margaret Fuller once

said, “if you have the knowledge, let others light their candles in it”; this is exactly what

we have tried to accomplish, and may the candle never blow out.


References

About Us. (n.d.). Retrieved from http://prontointernational.org/about-us/

DHS Program: Maternal and child health. (2009). Retrieved from http://dhsprogram.com

/pubs/pdf/FR173/09Chapter09.pdf

Evidence and impact. (n.d.). Retrieved from

http://prontointernational.org/what-we-do/evidence/


Tanzania, Statistics. (2013). Retrieved July 15, 2015, from http://www.unicef.org

/infobycountry/tanzania_statistics.html

Tanzania global health initiative strategy 2010 -2015. (2011). Retrieved from http://www.

ghi.gov/wherewework/docs/tanzaniastrategy.pdf

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TBD - ebaileybsn.weebly.comebaileybsn.weebly.com/uploads/5/2/1/2/52127071/final… · Web viewWhen a student graduates from a nursing school at ... to learn from our skilled nurses