The situation of nursing education in Latin America and the Caribbean towards universal health

Objective: to assess the situation of nursing education and to analyze the extent to which baccalaureate level nursing education programs in Latin America and the Caribbean are preparing graduates to contribute to the achievement of Universal Health. Method: quantitative, descriptive/exploratory, cross-sectional study carried out in 25 countries. Results: a total of 246 nursing schools participated in the study. Faculty with doctoral level degrees totaled 31.3%, without Brazil this is reduced to 8.3%. The ratio of clinical experiences in primary health care services to hospital-based services was 0.63, indicating that students receive more clinical experiences in hospital settings. The results suggested a need for improvement in internet access; information technology; accessibility for the disabled; program, faculty and student evaluation; and teaching/learning methods. Conclusion: there is heterogeneity in nursing education in Latin America and the Caribbean. The nursing curricula generally includes the principles and values of Universal Health and primary health care, as well as those principles underpinning transformative education modalities such as critical and complex thinking development, problem-solving, evidence-based clinical decision-making, and lifelong learning. However, there is a need to promote a paradigm shift in nursing education to include more training in primary health care.


Introduction
In the Region of the Americas, many people are unable to access comprehensive health services to achieve a healthy life, prevent disease, and receive primary health care (PHC) in a timely manner. The Pan American Health Organization/World Health Organization (PAHO/WHO) proposes the Strategy for Universal Access to Health and Universal Health Coverage to improve health outcomes and other basic objectives of health systems based on the right of each person to receive the best standard of health, without exposing people to financial difficulties (1) .
Universal Access to Health is defined as the absence of geographical, economic, socio-cultural, organizational, or gender barriers and is achieved through the progressive elimination of barriers that prevent all people from using comprehensive health services, determined at the national level, and in an equitable manner. Universal Health Coverage is defined as the capacity of the health system to respond to the needs of the population, which includes the availability of infrastructure, human resources, health technologies (including medicines), and financing. For the purpose of this study, Universal Access to Health and Universal Health Coverage are jointly called Universal Health (1) .
Nurses and midwives make up the largest part of the health workforce. However, there is great variation in the levels of initial education for nursing between countries of the Region of the Americas, as well as worldwide (2) .
Education is vital to train leaders in nursing and other health professions to create new mechanisms to achieve Universal Health. Nursing students must learn about the principles of social determinants of health, and adhere to the code of ethics and standards of the profession. The quality of education for 21 st century health professionals requires adequate infrastructure, partnerships, and curriculum design (2) .
The education of health professionals for the 21st century should also be oriented towards the principles of transformative and interprofessional education (3)(4)(5) .
The principles of transformative education include:  (3) . Interprofessional education (IPE) is one strategy to achieve transformative education and occurs when "two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes" (4) . Interprofessional education promotes teamwork and best use of valuable healthcare resources, empowering nurses to practice within the full extent of their education and training.
The World Health Organization (6) recommends that education institutions, to respond to transformative educational needs, adapt their institutional setup and modalities of instruction in alignment with interprofessional education and collaborative practice.
Realizing this agenda depends on giving priority to faculty development regarding facilitation of IPE to enable interprofessional learning (7) .
In September of 2016, the High-Level Commission on Health Employment and Economic Growth (8) , Nurses are essential members of the health workforce, and thus it is critical to ensure that nursing education prepares students to respond to needs of health systems and to work collaboratively in interprofessional teams (6) .
Interprofessional education has the potential to transform nursing education given that it promotes the development of collaborative practice attitudes, knowledge, skills, and behaviors (7) . Ensuring that nursing educational programs adhere to principles of transformative and interprofessional education will enhance the performance and productivity of qualified health professionals and result in improved care delivery (8) .
This study was conducted to assess the situation of nursing education in the Region of the Americas and to identify the extent to which baccalaureate level nursing education programs in Latin America and the Caribbean (LAC) are preparing graduates to contribute to the achievement of Universal Health in the region.

Methods
The proposal for the study was submitted to the Pan American Health Organization Ethics Review Committee (PAHOERC). The committee determined that Cassiani SHDB, Wilson LL, Mikael SSE, Morán-Peña L, Zarate-Grajales R, McCreary LL, et al. the project was exempt from PAHOERC's review because the proposal did not constitute research with human subjects and therefore did not need ethics review. The survey instrument was developed following an exhaustive review of the literature and was based on the Donabedian model, to assess the extent to which the Structure, Process, and Outcomes of the nursing education programs prepare students to contribute to Universal Health. Donabedian developed and introduced a model for evaluating health care quality based on concepts of structure, process, and outcomes (9) .
Structure focuses on the adequacy of the facilities and equipment, the suitability of the personnel and their organization, the policies and norms, administration of the organization, and communication, among others.
The items related to structure in the instrument assessed the numbers of students and faculty, school policies or guidelines, classrooms, and laboratories. Process focuses on actions carried out to achieve the objectives. The items related to process assessed curriculum and clinical practicum experiences for the students. Outcomes or results focus on concrete and precise measurements of the effectiveness to the actions planned and executed that demonstrate the fulfillment of the functions and the purposes established by the organization. The items related to outcomes for this project focused on the place of employment of the graduates, and whether they were integrating competencies related to Universal Health in their work.

The first section of the instrument focused on
Structure and included sub-sections related to:  Contact information was available for 1100 nursing schools (86% of the total), and each of these schools was invited to take part in the study. The final sample included 246 nursing schools (22% response rate) from 25 countries that responded to the survey after frequent contacts and reminders by phone and emails. Table 1 illustrates the response rate by country.  Table 3 presents the summary data regarding the number of Baccalaureate nursing students in each program for the total sample and each sub-sample.
Based on the standard deviation of the data presented, Central America and Latin Caribbean is the sub-sample with the most variation in the number of nursing students per program: their number of reported students per baccalaureate program ranges from 30 to 4,332. Table 4 illustrates the ratio of hours of clinical experiences in primary health care settings to hospitalbased clinical hours by total sample and by sub-sample.
For the total sample, the ratio was 0.63, indicating that students receive more of their clinical experiences in hospital settings than in primary health care settings.
This ratio was highest for Brazil (0.83), and lowest for Non-Latin Caribbean schools (0.26).
The items that had means of 4.0 or below are indicated in Figure 1, which also indicates the total sample or sub-sample group that had a mean below 4.0 on that item. It is important to recognize that these findings do not necessarily indicate that the responding schools are not implementing the structures, processes, and outcome evaluations reflected by the items.
Perhaps some respondents did not interpret the items to be asking about what is happening at their school.
However, the findings may be used to identify potential areas for ongoing program improvement.
Recognizing that the data were very positively skewed, we decided to expand our analysis to examine cells with means below 4.4, since we determined that 50% of the items for the total sample had mean scores that were 4.4 or lower. These items are illustrated in   (52) •

Nursing Program Evaluation
Carries out a periodic evaluation of its programs with students' participation (57) Results of program evaluation shared with educational authorities and professional organizations (58) The process of program evaluation assesses extent to which school prepares students to contribute to Universal Health (59)

Student Evaluation
Results of student evaluations are shared with students (62) •

Resources, Infrastructure, Relationships with Community/External Groups
Offers labs with equipment and supplies for students' development of clinical and care skills (4) • • • Faculty engages in professional practice related to Universal Health and PHC (6) • Employs nursing professors with experience in PHC and ability to develop and review program (7) • • Promotes collaboration with other nursing schools (national or international) or health related institutions (8  should be promoted to respond to the needs of the population and the health care models with more training in primary health care services (10) .
The training of nursing students in hospital settings more than in primary health care settings is Caribbean, as well as Andean Area and Southern Cone countries. Access to clinical laboratories and ICT has been identified as a priority for nursing education (12)(13) .
Findings from this study suggest that nursing schools should work to expand laboratory and ICT resources.
2) The programs that participated in the study reported having linkages and partnerships with national or Rev. Latino-Am. Enfermagem 2017;25:e2913.
international health institutions for practical training, consistent with recommendations by the American Association of Colleges of Nursing (14) and by Garfield (15) .
3) Between 37.8% and 42.7% of schools of nursing  (14) and the Association of Community Health Nursing Educators (16) .

5) The high mean scores of the responses regarding
curriculum reflects strong levels of knowledge Health values and PHC, with a focus on the country's healthcare context and priorities (8) .
7) According to the World Health Organization (4)(5) , education of health professionals should be oriented towards the principles of interprofessional education.
Interprofessional education is an important aspect of the curriculum that supports Universal Health and should be promoted in nursing schools. However, these results show that most students do not have opportunities to learn about, from and with students from other disciplines, and interprofessional teamwork is not part of the practical learning experience neither in simulation laboratories nor in the classroom. This is incongruent with recommendations from the American Association of Colleges of Nursing (14) and the Quad Council of Public Health Nursing Organization (17) and may reflect a low level of faculty experience with and preparedness to engage in such teaching/ learning approaches. To transform nursing education, priority needs to be given to faculty members' skill development regarding facilitation of IPE, enabling effective interprofessional learning (7) .
8 with studies by Frenk et al. (3) and the World Health Organization (5) .
10) The study findings suggest that many schools are not using clinical simulation or providing clinical training experiences in PHC services, in contradiction of the recommendations proposed by the World Health Organization (5,18) . This finding suggests that more learning opportunities and clinical simulation in PHC services should be provided to the students. 11) Findings also suggest that programs could be improved by increasing the involvement of students in Cassiani SHDB, Wilson LL, Mikael SSE, Morán-Peña L, Zarate-Grajales R, McCreary LL, et al. the planning of practical activities in primary care, as recommended by Keller et al. (19) .

12) The findings suggest the need for improvement
in periodic assessment of curriculum, with students' participation, and the divulgation of its results, as recommended by Mackey et al. (20) and the World Health Organization (18) .
13) Findings also suggest a need for improvement in development of quality monitoring, evaluation, evaluation reporting and improvement plans, as recommended by Keller et al. (19)  -Curricula need to be expanded to incorporate experiential learning for interprofessional and interdisciplinary work.
-Education programs need to take advantage of the regional infrastructure of national and international -Based on the successful experiences of countries in the region, schools should join together to define core competencies for Universal Health and to design a regional core curriculum for undergraduate nursing education that will produce graduates who are prepared to provide primary health care and to contribute to achieving Universal Health.
-Faculty with expertise in the primary health care arena, and those who are experienced in facilitating interprofessional education, should be hired by the schools to provide students with such important and transformative learning experiences.
-The need to increase the number of research projects related to nursing education as well as outcomes evaluation of training and nursing care.
-The need for extended access to the resources offered by the Virtual Health Library, with emphasis on the design of a specific section on Universal Health.
-The importance of addressing research priorities on Universal Health in the various national and international events in the region, to promote discussion, analysis and publication of results (21) .
-The need to gradually ensure shared decision-making for the training of health professionals by including in the regional, national and local goals the training of educational managers, deans and health service Rev. Latino-Am. Enfermagem 2017;25:e2913.
administrators in the design of policies, interventions and evaluation of results.
-The need to publish evidence of successful educational experiences and practices in the implementation of the Universal Health strategy.
-The importance of continuing studies to evaluate the role of nursing schools and to document their contribution to the health of the population over time.
-The responsibility of all health care professionals, especially educators, to urge various professional, educational and civil society groups to work in support of Universal Health initiatives.
-The need to disseminate successful experiences that have shown evidence of improvement in health with a focus on primary health care.
The instrument used for data collection was developed specifically for this study, and as such has some limitations. Although the instrument was assessed for content validity, given that this was the first time it has been used, the reliability of the instrument has not yet been established. There are also limitations associated with the sampling strategy.
Sampling for this research was not representative, as it relied on contacts available to the research team.
Additionally, the response rate was low, and the schools that did respond may not be reflective of the total population of nursing schools in the region. A more indepth study by country would allow a broader picture of each country and identify particular intervention strategies specific to the country. It is also possible that some respondents may not have been fully aware of all aspects of their school's curriculum and educational approaches, and this may have resulted in an incomplete picture being reflected in their responses. Finally, the data provided by the schools were self-reported; therefore, it is possible that the data were influenced by social desirability bias.

Conclusions
The data obtained in the study shows the heterogeneity in nursing education in the Latin