To teach is to learn: The impact of training and capacity building

International collaboration involving hospitals frequently includes the training of healthcare professionals, provision of actual healthcare, projects in healthcare management and the use of new innovative technologies and research. ¹ Traditionally, such collaborations are known to benefit the developing countries in terms of improvement in healthcare standards and quality. In more recent years, health leaders have begun to recognise that such partnerships no longer result in benefits for only one party but would lead to mutual benefits through a two-way flow of energies, experience, expertise and knowledge. ² Reported benefits accrued by the developed country provider include improved employee morale, heightened learning, better information sharing, personal and professional development, improved patient–provider relationships and a greater awareness of issues impacting health. ² Other benefits include awareness of different cultures, creativity and additional experience of practicing in a different setting. ³

China is one of Singapore’s key international partners, and the two countries commemorated 25 years of diplomatic relations in 2015. ⁴ Back in 2009, key leadership in SingHealth identified the need for our staff to engage and connect with healthcare professionals around the region so as to create a network for sharing innovative approaches and best practices. Therefore, the objectives of this paper are to describe an international partnership between Singapore Health Services and hospitals in China Provinces, as well as to provide an overview of the benefits to individuals and institutions involved in the partnership.

This partnership was supported by the Temasek Foundation International (a Singapore-based non-profit philanthropic organisation that funds and supports programs in capacity building). SingHealth provided teaching faculty to train healthcare professionals in China Provinces Hospitals in the area of nursing practice, risk management, quality management, clinical management as well as healthcare administration.

The three-tiered training program was to be delivered over a period of two years. Details of the program are as follows:

• I. Integrated Healthcare Clinical Nurses Specialist Program (IHCNSP)

In the first tier, the IHCNSP was designed to provide theoretical knowledge on various nursing care topics including rehabilitation skills, risk and quality management. The goal of IHCNSP was for nurses in China to gain a good understanding of the Nursing and Allied Health Management in an acute healthcare system and how it is being practice in Singapore. At the end of the program, trainees were expected to identify at least one area of improvement in their area of work.

• II. Train the faculty members in clinical management

In the second tier, those who had successfully completed the IHCNSP were trained for another two weeks in Singapore to become master faculty members. It was a requirement that each master trainer had to subsequently develop at least one new lesson plan or skill set that could be used to teach other nurses or allied health providers in their own institution.

• III. Hospital Leaders and Administrators Program

In the final tier, a group of hospital managers and administrators from China were invited to Singapore for training. These hospital managers and administrators were from various departments such as medical affairs, nursing operations, allied health, finance and human resources. During the two-week training course, the participants were provided with an overview of the Singapore healthcare system, health policies and SingHealth organisational structure. In-depth group discussions and case presentations were also carried out. At the end of the training, the participants were also expected to identify and present an area of change within their own institution.

A two-pronged approach was used to collect data for evaluation. First, feedback forms were provided after each training session to gather responses from the trainees. Data were analysed using descriptive statistics and responses to open-ended questions were analysed using thematic analysis. A follow-up survey was also conducted 12 months after the program to evaluate any practice changes that were made.

Second, the impact of the training on the faculty members was assessed through a survey (using open-ended questions) of 18 faculty members two months after their first visit to the hospitals in various China Provinces. Faculty members were locally trained nurses with at least five years of clinical experience and consisted of advance practice nurses and speciality care nurses. Their responses were analysed using thematic analysis.

The participants were made up of clinical nurses, head nurses, managers and administrators from various hospitals from the Provinces of China. They were asked to evaluate the program, the faculty members (Trainers) and their learning using a 4-point Likert scale (exceed expectation to needs improvement).

The program met the clinical nurses’ expectations regards their learning objectives (57%, n = 254). Up to 80% (n = 234) of the trainees agreed that the teaching methods were effective and most of the trainees rated their trainers as knowledgeable (70%, n = 155). The trainees also felt that their interactions with the trainers exceeded their expectations (95%, n = 473) and had reported a significant increase in knowledge from 69% to 78% at the end of the program.

In total, 170 improvement projects were implemented across the different hospitals in China. These projects were headed by the master faculty members who were trained in Singapore. The projects on quality were mainly on the enhancement of patient safety and quality. For example, in Ningxia Medical University General Hospital, they implemented a patient safety package to improve the following six key quality areas: (1) bedside communication board; (2) pressure ulcer education booklet; (3) turning flip chart; (4) “Do Not Disturb” medication vest; (5) first-in-first-out (FIFO) method for inventory management; and (6) fall precaution stickers on patients’ wrist tag.

Communication is the key component in ensuring patient safety; therefore, the hospital implemented a bedside communication board to inform the healthcare team of patients’ dietary restrictions, physical limitations or any other important care to highlight during each shift. The hospital also created an educational booklet to educate nurses and patients on pressure ulcer prevention strategies. In addition, they designed a turning chart to remind the nurses to change the patient’s position every two hours. The hospital implemented a “Do Not Disturb” medication vest for their nurses to prevent interruption during their medication round. Medications and other patients’ consumables were also stored in the FIFO manner to prevent the use of expired products. Finally, a fall identification sticker was introduced to identify potential fallers. This safety package project has won them third prize at a national-level hospital competition in China.

The following three themes were identified: development in teaching skills and capability; motivation by enthusiasm of trainees; and enhanced knowledge acquisition.

Trainers discussed that their educational trip in China taught them to be creative in their problem-solving and that they have learned new ways to deliver teaching content. They also felt more confident and motivated to do better (teaching) in the future:

The learners came from various hospitals and different departments. The nursing care and working process were different between each institution. Thus, we had to modify the way we deliver the lecture as we go along. (T 3)

Conducting this training has increased my self-confidence as a trainer and motivated me to achieve a higher personal and professional level. (T 12)

Faculty members verbalised that they were moved by the participants’ enthusiasm to learn and the respect they received from the trainees:

The Qinghai nurses were very enthusiastic in learning and treated us with a lot of respect, even calling us “Lao Shi” (Teacher in Mandarin)…their learning attitude and spirit is fantastic and I also learned a lot from them. (T 5)

Although the hospitals may not be as advanced compared to ours, the nurses persevered to pursue their ultimate goal of delivering quality patient care, which made me very moved by their motivation. (T 12)

Faculty members acknowledged that the skills and knowledge acquired through this partnership were unique and unexpected, and there was a sense of camaraderie:

Even though the main aim of this trip was to do teaching for the nurses in China, the experience and knowledge that I have gained is way more than what I have delivered to them. (T 6)

When it comes to teaching in Mandarin, much effort is needed to translate the information into Mandarin, and requires repeated practices and “rehearsal” to ensure that we are saying the word accurately so our trainers worked together and helped each other as we practice daily before the following day teaching session. (T 2)

Nurses have been actively providing culturally appropriate global healthcare since the days of Florence Nightingale. ⁵ Nightingale emphasised the importance of experiential education rather than relying on theory alone and was also an advocate for the individual–community–global connection in educational projects internationally. ⁶ This paper provides an example of how an international partnership between nurses in Singapore and China has resulted in learning for all involved.

Traditionally, global nursing activities are led by academia, voluntary organisation or governmental bodies; however, this program is unique as it was led by nurse leaders and educators from an acute tertiary hospital and made possible through generous support from a non-profit philanthropic organisation and the hospital’s management. Similar to previous literature, faculty members found it challenging to teach international students but, nevertheless, they appreciated and respected the diversity. In addition, they also reflected on their teaching, and acknowledged the need to incorporate strategies that addressed international student learning needs and to internationalise their curriculum so that the key principles were accessible to the students. ⁶

The partnering hospitals in China also proved their capability in adopting best care practices, which had many positive impacts on their clients and organisation.

Building capacity through the sharing of knowledge and best practices is pertinent to global healthcare excellence, with benefits to both the developed and partnering developing country. Improved work processes and patient care was evident in the recipients’ hospitals, while the act of teaching has enhanced knowledge acquisition among faculty members.