The need for evidence in nursing practice in Latin America

Applied Nursing Research 19 (2006) 220 – 222 www.elsevier.com/locate/apnr International Column The need for evidence in nursing practice in Latin America Ilta Lange, RN, RScNa,4, Kathryn Leonhardy, PhD, RNb a Escuela de Enfermeria, Pontificia Universidad Católica de Chile, Santiago, Chile School of Nursing and Health Studies, Georgetown University, Washington, DC 20057-1107, USA b As in most parts of the world, in Latin America, personnel providing nursing services make up the largest health workforce in most countries, although data about the exact number of nursing personnel are hard to find. At the same time, there is a confusing array of categories and levels of nursing personnel throughout the region, and, universally, there are few nurses who are university prepared. The categories of nursing personnel differ among countries; however, in most of Latin America, baccalaureate education is available only to an elite few, whereas most receive technical preparation at a diploma level through a training program that lasts for approximately 3 years (technical nurses). Auxiliary nurses make up approximately 70% of the nursing workforce in Latin America. Although the training of nurse auxiliaries varies significantly from one country to another, the trend is to provide 1 to 1.5 years of theoretical and practical training, most of which is on-thejob training. The roles of nurses in different levels are not well regulated. In fact, work that would ordinarily be completed by baccalaureate-prepared nurses is often delegated to nurse auxiliaries during night and weekend shifts owing to a lack of professional nurses. In examining the current status of nursing education beyond the baccalaureate level, only in recent years have nurses been receiving advanced degrees in the region. The language barrier among many Latin American nurses has been an obstacle to receiving advanced degrees in North America and in other non-Spanish-speaking regions. The stratification of the profession in the region provides a major obstacle to cohesion and advancement. Having most nurses educated at the technical level does not facilitate either the consumption and utilization of research literature or the practice of research itself. There have been a few local postbaccalaureate programs in nursing developed in recent years. Several years ago, Brazil developed doctoral programs in nursing. More 4 Corresponding author. 0897-1897/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2006.08.001 recently, doctoral programs have been developed in Colombia, Chile, and Mexico. Albeit few, there are nurses who have received doctoral preparation in North America. This is definitely a step in the right direction. However, the lack of a critical mass of nurses with advanced degrees has limited the development of infrastructure to facilitate research and the development of a locally relevant research database demonstrating the effectiveness of nursing care in the Latin American context. Doctoral education is expensive and time consuming. Sending nurses to other countries for education should result not only in a doctoral thesis but also in a long-standing commitment to advance the profession of nursing among colleagues of different nationalities. One organization that has had an impact on the advancement of nursing and other health professions in Latin America is the W.K. Kellogg Foundation with the UNI Program. The foundation provided funding for capacity building through educational development and cooperation. Through these experiences, nurses have had the ability to develop relationships across the North–South divide to advance research in both places. Although this program is admirable, it is not specifically focused on the development of research capacity among nursing personnel. More opportunities for developing collaborative research need to be fostered on both sides of the equator to develop an evidence base of nursing practice in Latin America. In addition to having few doctorally prepared nurses, there are few nurses in Latin America who have access to current research literature or even current nursing texts in their language. Nurses in developed countries are accustomed to having easy internet access, in addition to working for institutions that are willing to pay the high fees for institutional subscriptions to a variety of different journals. The daily reality for nurses in Latin America is that internet access can be limited to computers available in places of work such as health as well as educational institutions and accessible libraries. Even if access to the internet is available, because most research articles are in a language other than Spanish, the language barrier provides an I. Lange, K. Leonhardy / Applied Nursing Research 19 (2006) 220 – 222 additional obstacle. Computers with current technology, although increasing, are still often out of reach for many nurses, and the electronic access that nurses in the North take for granted is rarely so accessible. The World Health Organization has facilitated access to some electronic journals in low-income countries; however, in Latin American countries that are considered middle income, such as Chile, free access does not exist and individual as well as institutional subscriptions are prohibitively expensive for most. As noted, there are also few nurses who have the educational background to be able to read and glean necessary information from the literature for incorporation into their practice. In addition, most research articles are still published only in English, thus creating an additional barrier to access, understanding, and application for those who are unable to read scientific journals in English. Another major obstacle to advancing nursing in Latin America is the lack of research funding available to nurses. Unlike nurses in the United States who have access to funding from the NIH (National Institutes of Health) through the National Institute for Nursing Research and other institutes, foundations, and university sources, nurses in Latin America do not have as ready access to these funds. Although many research endeavors could be undertaken with minimal funding, the lack of access to funding even for pilot work provides a significant barrier to the development of a research database. Nurse researchers in the United States could certainly facilitate this work through collaboration with Latin American colleagues who could facilitate replication and adaptation of American nursing research into the local context. Certainly one of the most accessible mechanisms for doing this is to apply for funding from the Fogarty International Center of the NIH. Up to this point, very limited Fogarty funding has been granted to nurse researchers; of fundings granted, even less have been focused on Latin America. Most fundings from the Fogarty International Center have been for very targeted training on capacity building in AIDS research. This is a critical juncture in nursing in Latin America. The evidence base in nursing needs to be developed; moreover, research must be disseminated and communicated in a way that is accessible to practicing nurse clinicians. Research must be undertaken to examine outcomes that are sensitive to nursing care. The evidence for nursing education at the baccalaureate level exists in North America. This evidence base does not currently exist for Latin American nurses; for the field as a whole to advance, it must be developed. This is for the purpose not only of advancing clinical practice but also of advancing the profession itself. Low-cost strategies that might help advance this cause would be the development of an online colleague relationship that would facilitate dialogue and idea development. This could be done in the form of a discussion board or a chat room through which colleagues with similar lines of research log on and exchange ideas. In addition, shared online courses at the undergraduate and 221 graduate levels would also facilitate North–South dialogue. Once the case is made that nurses with more and better education have an impact on the health outcomes of populations, nurses may at long last find a more respected place among health care providers in Latin America. Commentary on the need for evidence in nursing practice in Latin America There are many similarities between Latin America and Taiwan with regard to nursing and evidence-based nursing practice. Evidence-based nursing practice, along with the evidence-based medical practice development, has become a major issue in Taiwan since 1998. As a result, several medical centers in Taiwan put more effort into developing evidence-based practice through activities such as implementing an online learning program, developing a career ladder program, and encouraging nurses to participate in clinical research and to publish their results. However, there are several factors that are obstacles for developing evidence-based nursing practice in Taiwan. First, similar to the case in Latin America, approximately 70% of the nursing workforce is composed of vocational and junior college graduates. Vocational schools admit graduates of junior high schools and offer 3-year basic nursing education. Junior college programs provide a 5-year program for junior high school graduates and a 2-year program for registered nurses who graduated from vocational schools. These nurses have difficulty reading and understanding most nursing research articles that are published in English. In addition, they have difficulty appraising good research articles. Five years ago, the government of Taiwan began to promote vocational schools into junior colleges and higher institutions to improve nursing education and nursing qualifications. The second obstacle is the gap between research and practice. Although nurses with masters degrees or PhD degrees have been more common in Taiwan in the last 10 years, they primarily are located in academic settings, resulting in a big gap between research and practice. Adding to the problem, the clinical frontline nurses do not receive research training as part of their educational programs and have negative attitudes toward research. Third, the condition of the nursing profession in Taiwan faces a number of challenges. In 1995, the government of Taiwan implemented a national health insurance program. This resulted in health care cost control becoming a great challenge for hospitals. As a result, several hospitals reduced the number of nurses employed to decrease personnel costs. This reduction pushed more nurses into leaving their position. Other factors that contribute to the nursing shortage include low salaries as compared with other health service positions, high workload, and lack of professional development opportunities, resulting in a high nursing turnover rate.