Strengthening universal health: development of a nursing and midwifery education quality improvement toolkit

Objective: to present the development of a toolkit for education quality improvement in universal health and primary health care, targeting schools of nursing and midwifery in Latin American and Caribbean countries. Methods: an expert work group conducted a systematic literature review, selected key content and completed toolkit drafting, using an iterative consensus approach. International partners reviewed the toolkit. Cognitive debriefing data were analyzed, revisions and new tools were integrated, and the final version was approved. Results: twenty-two articles were identified and mapped as resources. The Model for Improvement, a data-driven approach to performance analysis, was selected for its widespread use and simplicity in carrying out the following steps: 1) organize a team, 2) assess improvement need regarding universal health and primary health care education, 3) set an aim/goal and identify priorities using a matrix, 4) establish metrics, 5) identify change, 6) carry out a series of Plan-Do-Study-Act learning cycles, and 7) sustain change. Conclusions: the Education Quality Improvement Toolkit, developed through stakeholder consensus, provides a systematic, and potentially culturally adaptable approach to improve student, faculty, and program areas associated with universal health coverage and access.

3) adopting the principles of interprofessional education (IPE) using practical team-based experiences that reflect country specific healthcare contexts and priorities around PHC and UH (1) .
In the footsteps of this study, the PAHO/WHOCC in International Nursing at the University of Alabama at Birmingham (UAB) was tasked to develop "Universal Health and Primary Health Care: a Plan for Nursing and Midwifery Education Quality Improvement." This plan included an education quality improvement (EQI) Toolkit to assist nursing and midwifery programs in evaluating and improving structure, process, and outcomes within the framework of transformative education and competency-based interprofessional collaborative practice (IPCP). The overarching goal for this international multi-centric partnership study was to improve UH and PHC in LAC countries. In this paper, we will describe the development, evaluation by partners, and revision of the EQI Toolkit aimed to guide QI activities in nursing and midwifery education.

Transformative Education
In the era of a global economy, sweeping technological advances, growing disparities and increased focus on sustainability, higher education for health professionals is rapidly evolving. Pathways for transforming higher education to strengthen health systems in an interdependent and interprofessional world have been the focus of two simultaneous landmark reports (2)(3) . Transformative education encompasses principles of critical thinking, team work, creative adaptation, integration of education into health systems, resource sharing, networking and partnerships (2)(3) . Interprofessional education, where students learn from each other outside traditional disciplinary silos, is a pre-requisite to transformative education (3) . Preparing the future healthcare workforce for IPCP, different disciplines working effectively together in teams with patients, families, caregivers, and communities, is a prerequisite to delivering the highest quality care (3) . The High-Level Commission on Health Employment and Economic Growth, established by the United Nations (UN), WHO, and other agencies, recommends scaling up transformative and lifelong learning for the healthcare workforce (4) . To move forward the UN 2030 Sustainable Development Goals (SDGs) agenda, nurses and midwives must be prepared to practice and thrive in an ever-changing environment, assessing evidence and working collaboratively with other healthcare professionals to meet the needs of diverse populations.
Universal health (UH) access and coverage are two of the main indicators for ensuring healthy lives and promoting well-being for all (SDG #3). Defined as "the absence of geographical, economic, sociocultural, organizational, or gender barriers" universal access to health is achieved through "the progressive elimination of barriers that prevent all people from having equitable use of comprehensive health services determined at the national level" (5) . Universal health coverage (UHC) is a financial protection arrangement for health for all.
It is often achieved through some form of national health insurance program to serve the needs of the population (6) . Closely tied to both concepts, PHC aims to achieve better health for all through reform in universal coverage, service delivery, public policy, and leadership (7) . Organizing health services around peoples' needs and expectations, and increasing Recently, the potential contribution of nurses and midwives towards achieving UH has been a focus of the Nursing Now Campaign (8) . Based on the premise that investment in nursing will enable nurses to achieve their full potential, nursing and midwifery education programs are urged to prepare graduates in promoting UH and PHC.
In order to prepare competent and skillful entrylevel nurses and midwives in providing PHC and UH, educators must meet a minimum of core competencies.

Background -Nursing and Midwifery Education in Latin
America and the Caribbean Entry-level nursing and midwifery education in LAC countries reflects regional disparities in terms of geography, politics, economy, and culture (11) . Variation in levels of educational preparation affect workforce capacity, in both numbers and skill mix, which ultimately influences care quality. For example, some Eastern Caribbean countries have more than 40 professional nurses per 10,000 population, whereas most of the Spanish-speaking countries in the region have less than 10 per 10,000 (12) .
Similarly, teaching and practicing midwifery varies greatly, with an ongoing debate over education and care models (13) . Midwifery can be practiced by obstetric nurses, nurse-midwives, professional midwives, and in some countries, by traditional midwives, with education ranging from lay midwifery to undergraduate and/or post-graduate preparation (14) . For countries with low numbers of skilled birth attendants and high maternal mortality rates, it has been recommended that Ministries of Health consider professional midwifery as a key to improving maternal and perinatal health (14) . Therefore, strategies to strengthen the quality of nursing and midwifery education are vital for establishing a competent workforce and must be set in the context of each country.

Professional Education
Quality improvement, as we currently know it in healthcare and education, originated in 1939 with control charts to track variation in manufacturing defects and the "learning and improvement cycle" known in healthcare as the Plan-Do-Study-Act (PDSA) cycle (15) . Studying what is occurring and its variation patterns was viewed as a first step before intervening to improve quality. The impact of specific QI approaches varies, depending on the context in which they are implemented (16) . In general, success of a QI program is determined by an organization's commitment to monitor, assess, improve, and embed continuous improvement into the organization's culture for seeking higher levels of performance.
Understanding systems and how they interact is critical, since improvement in one area of operations may induce unintended consequences, and even harm, in another area (17) . Focusing improvement efforts on customers who benefit from the system is fundamental, whether they be patients, students, providers, or teachers. A team approach, involving more than one discipline, builds creativity, enthusiasm, and commitment to the work. Focus on collecting and using data, constant monitoring, and tracking the same elements throughout the iterative PDSA cycles is paramount to successful QI endeavors. The WHO has defined QI as "An approach to improvement of service systems and processes through the routine use of health and programme data to meet patient and programme needs." (7) This versatile definition can be applied to both healthcare delivery and educational programs. Improving quality in healthcare requires an appreciation and understanding of system complexity, critical components, and most importantly, the cultural context and population served (18) . Educational program quality can be defined as the degree to which didactic and clinical education increases the likelihood of desirable outcomes, consistent with current knowledge. These educational outcomes should reflect competencies of nurses and midwives as they relate to providing patient care.
In light of the above priorities and needs for highly competent nursing and midwifery professionals who are well-equipped to promote UH and PHC, this article aims to present the development of an EQI Toolkit for schools of nursing and midwifery in LAC countries.

Method
Following the Standards for Quality Improvement Reporting Excellence (SQUIRE), this multi-centric study is outlined in sequential phases ( Figure 1).  (19) provided the framework for toolkit design and was operationalized through the QI process; a data-driven, formal approach to performance analysis in nursing and midwifery educational programs and the systematic efforts to improve it (16) .  Because of substantial educational differences among programs, it was clear that the toolkit would need to be adaptable to country/language/culture/setting, plus be user friendly and simple to use. For clarity, a glossary of terms with appropriate references was developed as an appendix to the EQI Toolkit.

Phase 2 -Literature review
The first toolkit version was developed using brainstorming and modified affinity grouping techniques. This process allowed the expert work group to generate, categorize, and choose among ideas by posting common themes on a flip chart (20) . For this project, ideas were recorded using a laptop and were immediately projected onto a screen for everyone to see and compare notes. Each work group member took responsibility for drafting content and tools for inclusion. An iterative process was used to select and connect the key elements to form a coherent resource for the next phase of review.

Phase 4 -EQI Toolkit user evaluation and revision
To obtain user evaluation, the qualitative method of iterative processing cognitive debriefing was applied. Four international stakeholders were invited as reviewers through three partnering PAHO/WHOCCs.

Universal Health and Primary Health Care: A Toolkit for Quality Improvement in Nursing and Midwifery Education"
Please answer the following questions in as much detail as possible.

1.
Tell us about your impression of this tookit? 2.
What are the top two strengths and weaknesses of this toolkit? 3.
In general, is the structure clear, easy to understand and follow? 4.
In general, is the content clear, easy to understand and follow? 5.
Overall, is the toolkit relevant to your school's situation? 6.
How likely are you to use this toolkit in your school?    Content analysis of selected articles revealed the following themes: 1) assessment -evaluation;

Literature review
2) continuous quality improvement (CQI) -accreditation; 3) curriculum plan development; and 4) implementation -   • Undergraduate nursing students made the most complaints; failure and dismissal from program was the most frequent taxon, with grading, teaching, and testing the next highest • **CQI: 1) reduce number of future complaints by early intervention and process improvement activities, 2) meet national accrediting organization requirements. Assessment and evaluation are essential to the QI process, reflected in select articles (1,(27)(28)(29) . Despite the labor intensive nature of data mining, it is argued that gap analysis and feedback, as a method to assess core competency in the curriculum, could decrease content saturation and promote active learning (28) .

**CQI -Accreditation
Program evaluation is achieved through course reviews, student surveys, pre-and-post-program assessment of students' knowledge/skills, and faculty interviews about their experiences with new teaching methods (27,29) .
It is recommended that evaluation protocols include linkages to external criteria for evaluating the plan itself, while the teaching-learning process should be subject to ongoing QI (27) . This is consistent with findings from an extensive survey of nursing schools in LAC countries showing nursing program evaluation, student evaluation, and outcomes as the top priorities for QI initiatives (1) . Using an original self-assessment tool, the same survey revealed the heterogeneity of education, with a clear need to strengthen training in UH, PHC, and transformational education. Schools seeking accreditation are highly encouraged to develop periodic evaluations of curricula and programs with participation from their students, as well as to share the results with educational authorities and professional organizations (1) .
The CQI-accreditation approach is described in select articles (24,26,(30)(31)36,38,40,42) . It provides metrics and information to administrators and faculty regarding the rigor of programs and the potential of graduates. CQI as a hallmark of the accreditation process, identifies areas for improvement and allows for planning (30)  are also examined as an ongoing CQI process (26,42) . Brown and Marshall (24) use a quality enhancement plan (QEP) to assess key factors affecting program outcomes. They demonstrate CQI effectiveness in increasing NCLEX-RN pass rates, improving student advisement, and raising student satisfaction. Other effective interventions across programs include: early identification of students at risk, timely remediation, and program policy enforcement (31) .
Of equal importance is surveying past graduates of their opinion and feedback about strengths and weaknesses of the school/program (36) .
For curriculum plan development, faculty collaborations and partnerships were instrumental in augmenting evaluation tools and processes for clinical learning, expanding clinical capacity, and improving clinical experiences (22) . Armstrong et al. (23) use the

Quality and Safety Education for Nurses (QSEN)
competencies to enhance a competency outcome performance assessment (COPA)-based curriculum.
Reflective components of practice-based learning activities based on QSEN competencies engage students in evaluating: 1) level of comfort with being a change agent, 2) unit climate for change, and 3) delegation and communication skills (39) .
Implementation case studies have shown that students' readiness to learn and ability to embrace concepts, processes, and outcomes measurement is enhanced by early teaching of systems and QI thinking within an undergraduate curriculum (34)(35) . Exposing students to real world experiences that underline the significance of these skills helps bridge the educationpractice gap (35) . A study with United Kingdom student nurses showed that they can successfully overcome their fears and meet the QI practicum challenge, if adequate support mechanisms are in place (32) . Doing a practicum as a compulsory assignment in a largescale cohort is achievable, if there is balance between motivation to learn and fear (32) . promising results (37,41) . Furthermore, use of patient simulators and the concierge model of simulation can be an effective strategy for deliberate practice of skills and standardized exposure to limited scenarios (25,33) .
Clinical simulation and debriefing are effective

User assessment and regional variation
As part of the evaluation process, all four international reviewers answered questions using

Components of final EQI Toolkit
The toolkit includes an introduction to and definitions of UH, PHC, and IPCP concepts based upon WHO (6) and PAHO (5) documents. An overview of nursing and midwifery education presents the core competencies for educators (9)(10) , followed by an introduction of QI in nursing and midwifery education. The expert group adopted • Begin data analysis.

Model for improvement
How will we know that a change is an improvement?
What change can we make that will result in improvement?
What are we trying to accomplish?  Second, a "Prioritization Matrix" along with a completed example were included. Together, these items assist the improvement team to prioritize up to three items/areas requiring improvement, stemming from the results of the previously described self-assessment tool.

Plan Act
The matrix guides the team in using weighed criteria to score improvement project options and use criteriabased evidence when choosing those to begin first.
Priority criteria can be tailored for each school/program; cost, expertise, space, location, and organizational culture are some of the most frequently encountered.
Third, a "PDSA Cycle Worksheet" consisting of four sections along with a completed example was provided.
The first section, "Plan", asks the improvement team to detail the plan for a test of change; the improvement to be implemented, who will be involved, what are the components of the change, when will the change begin and end, where the project will occur, and predictions regarding the change. The team is asked to define all measures (process, outcome, balancing and system measures), name their data source and frequency of measure, and assign responsibilities. The second section, "Do", reminds the team to determine the number of participants, carry out the change or test and collect planned data, while documenting problems and unexpected observations. In the third section, "Study", improvement team members are guided to analyze data and summarize lessons learned, then compare data to a priori predictions and reflect on what was learned. Last, in the "Act" section, the team is prompted to refine the change based on what was learned, and consider whether to adapt, adopt, or abandon the change.
The fourth appendix includes two improvement exemplars for teaching UH and PHC competencies.

Discussion
The final EQI Toolkit is freely available through the UAB School of Nursing website (43) . Ultimately, the toolkit's endorsement will be a measure of its comprehensiveness, relevance, and adaptability to different settings, institutions, and countries.
Extension of its use to other types of programs, such as graduate, post-graduate, and interdisciplinary could signal greater adaptability and inclusiveness.
Its potential for better educational outcomes and systematic QI is highly anticipated. Given that currently there is no mandatory accreditation for most nursing and midwifery programs in LAC countries, the EQI Toolkit could serve as a guide for institutions towards developing standards and procedures for ongoing, systematic internal quality control and improvement. Key higher education stakeholders can play an important role by providing strong incentives and building capacity at multiple levels (e.g., among individual faculty, interprofessional teams, across schools and institutions). Examples include QI education and training, technical assistance, ongoing mentoring or coaching, and financial support towards QI infrastructure development and staff. Improvement science coursework could also be introduced to undergraduate students.
Learning the science and application of improvement is becoming more pertinent to nurses and midwives around the globe. The Nursing Now (8) global campaign has recently teamed up with the Institute for Healthcare Improvement (IHI) Open School to offer several free online modules on QI, program management, and culture change (43)(44) .
Although mostly targeting the healthcare environment, has been sufficiently pilot tested and refined. Further cultural and organizational adaptation to each country and/or setting is needed to tailor and refine the toolkit.

Conclusions
Strengthening UH and PHC through transformative education has been at the core of a PAHO/WHO "call for action" for preparing a competent global nursing and midwifery workforce. Building capacity in LAC countries, many with low ratios of nurses and midwives to population and great variation of professional entrylevel education, is paramount. Based on a systematic review of available literature, and recognizing that substantial educational differences occur among programs, the EQI toolkit is poised to be adaptable to individual characteristics or circumstances within any nursing or midwifery undergraduate school program.
The toolkit offers a dynamic model for a QI plan that could be adopted by educational programs in LAC countries to address weaknesses in UH and PHC within the framework of transformative education and IPCP.
Inherent in this work is the acknowledgement that nurses and midwives have important leadership roles to play in health promotion, disease prevention, and reducing morbidity and mortality. A strength of this toolkit stems from its development in partnership with international stakeholders. Future activities will focus on how this educational intervention can be disseminated, evaluated and further improved for broader application.

Aknowledgements
We would like to thank the following individuals,