International collaboration Brazil-Canada: coordinating a professional development course for nurses on health literacy

Abstract

Objective

Report the experience of professional development in the context of the international cooperation between Canada and Brazil by means of the implementation of an update course for nurses on community health literacy.

Method

Experiences were reported regarding the course, which was organized by ten professors (nine Brazilians and one Brazilian-Canadian) with planning activities from September to December 2019. mostly with the use of digital tools and discussed the course’s implementation and implantation from January 6 to 31, 2020 in the cities of Brasília, Goiânia, and Recife.

Results

The course, as an institutional internationalization project, was supported by teaching, in-service education, research, and management in order to collaborate internationally. The project was led by one Canadian university in collaboration with graduate nursing programs from three Brazilian federal universities, facilitating the transfer of health knowledge through educational activities and connecting institutions from different countries.

Conclusion and implications for practice

This international collaboration in nursing education made it possible to exchange innovative knowledge to overcome challenges and promote scientific collaboration. The success of this experience led to recommendations that can corroborate multi-institutional partnerships. Detailing this experience constitutes a tool for its replication and adaptation to any Latin-American academic context, thus enhancing the internationalization process.

Keywords:
Professional Training; International Cooperation; Staff Development; Education, Nursing; Health Literacy

Resumo

Objetivo

Relatar a experiência da capacitação profissional no contexto da cooperação internacional Brasil-Canadá por meio da implantação de curso de atualização de enfermeiros sobre letramento em saúde comunitário.

Método

Relato de experiência do curso organizado por dez docentes, nove brasileiras e uma brasileira-canadense, com atividades de planejamento, no período de setembro a dezembro de 2019, majoritariamente com uso de ferramentas digitais e as de implantação, de 06 a 31 de janeiro de 2020, nas cidades de Brasília, Goiânia e Recife.

Resultados

O curso, enquanto projeto de internacionalização institucional, apoiou-se no ensino, educação em serviço, pesquisa e gestão, para colaborar com a parceria internacional liderada por uma universidade canadense e três programas brasileiros de pós-graduação em Enfermagem, sendo esta transferência de conhecimentos na área da saúde na modalidade de atividade educativa, uma possibilidade para conectar instituições de diferentes países.

Conclusão e implicações para a prática

Esta cooperação internacional de educação em Enfermagem possibilitou a troca de conhecimentos inovadores para superar desafios e colaborar cientificamente. O êxito dessa experiência sinalizou recomendações que possam corroborar o bojo de parceria multi-institucional. O detalhamento desta experiência constitui ferramenta para sua reprodução e adaptação a qualquer contexto acadêmico latino-americano, impulsionando assim, o processo de internacionalização.

Palavras-chave:
Capacitação profissional; Cooperação internacional; Desenvolvimento de pessoal; Educação em enfermagem; Letramento em saúde

Resumen

Objetivo:

Relatar la experiencia de la capacitación profesional en el contexto de la cooperación internacional Canadá - Brasil mediante la utilización de un curso de actualización de las enfermeras sobre alfabetización comunitaria en salud.

Método

Informe de experiencia del curso organizado por diez profesores, nueve brasileñas y una brasileña-canadiense, con actividades de planificación, durante el periodo comprendido entre septiembre a diciembre de 2019, en su mayoría utilizando herramientas digitales y las de implementación, del 6 al 31 de enero de 2020, en las ciudades de Brasília, Goiânia y Recife.

Resultados

El curso, como un proyecto de internacionalización institucional, fue apoyado en la enseñanza, la educación en el servicio, la investigación y la gestión, para colaborar con la asociación internacional liderada por una universidad canadiense y tres programas brasileños de postgrado en Enfermería, siendo esta transferencia de conocimiento en el campo de la salud en forma de actividad educativa, una posibilidad de conectar instituciones de diferentes países.

Conclusión e implicaciones para la práctica

Esta cooperación internacional en la educación de enfermería ha permitido el intercambio de conocimientos innovadores para superar desafíos y colaborar científicamente. El éxito de esta experiencia ha señalado recomendaciones que pueden corroborar la asociación multi-institucional en su seno. El detalle de la experiencia constituye una herramienta para su replicación y adaptación a cualquier contexto académico latinoamericano, impulsando así el proceso de internacionalización.

Palabras clave:
Capacitación Profesional; Cooperación Internacional; Desarrollo de Personal; Educación en Enfermería; Alfabetización en Salud

INTRODUCTION

To facilitate internationalization, especially in education¹ and health,² it is necessary that leaders have the political will^1,2 to strengthen Brazil's image so that they can become continuous partners with high-income countries. High income countries have multiple sources of financing, whether governmental or private, to fulfill managers’ and educators’ commitments to internationalization.¹ Social inequity, one of the global problems regardless of the level of economic development,³ jeopardizes the effectiveness of health promotion actions, so collaboration with high income countries can help partner countries develop ambitious actions in exchange for expertise and knowledge.

One strategy to reduce social inequities and foster the transfer of knowledge to overcome global challenges is to focus on international cooperation in higher education.⁴ Scenarios of economic instability can motivate action based on solidarity, humanistic values, and intercultural dialogue by international institutions of higher education in the global context. One such action is the establishment of international partnerships. Thus, the transfer of knowledge can contribute to the discovery of solutions that facilitate the circularity of knowledge.⁴

In the last 20 years of nursing science, internationalization has been emphasized, supporting the incorporation of curricular changes to improve professional practice and research and affecting the demand for the development of policies to improve global health.⁵ In the Brazilian graduate programs, policies to advance the quality of scientific production, guided by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), have highlighted the importance of internationalization to increase the excellence of programs and the qualification of researchers.⁶ The expansion of graduate programs (PPGs) in Nursing is recent, and in the North and Midwest regions, there is still a shortage of this level of education with the quality required by the area of Nursing / CAPES.⁷ In addition to excellence in the training of masters and doctors in nursing, internationalization strengthens PPG partnerships,⁸ including the creation and expansion of collaborative networking.

Understanding this relationship made possible the organization of actions that could contribute to the process of internationalization. The stages of this process are described in this manuscript, which aims to report the educational experience in the context of international cooperation Brazil-Canada through the implementation of a professional training and development course for nurses on community health literacy.

METHOD

The results in this manuscript are accounts of the experience of the course’s coordinators during the planning activities, which were mostly carried out through online meetings from September to December 2019, and during implementation from January 6 to 31, 2020, in the cities of Brasília, Goiânia and Recife. In order to operationalize actions that support international cooperation between Brazil and Canada,⁹ a Brazilian-Canadian professor articulated the dialogue between Brazilian and Canadian universities, to which she was linked. Initially, the PPG coordinators issued letters of support that were attached to other documents as per the application submitted by the Canadian nursing professor, resulting in the financing of the proposal by Global Affairs Canada. The proposal discussed the implementation of a course on the theme of community health literacy and was aimed at professors, undergraduate and graduate students, as well as health services nurses, also as staff development initiative. The purpose of this course was to provide participants with strategies for promoting evidence-based community health literacy for scientific innovation.

With funding obtained in 2019, the Brazilian-Canadian professor traveled from Canada to Brazil in 2020 and met with representatives of the PPGs in nursing from three Federal Universities, located in the Northeast and Midwest regions, which, in collaboration with the Brazilian Health Literacy Network (Rede Brasileira de Letramento em Saúde (REBRALS)), established a collaboration. This team consisted of 10 professors under the coordination of the Brazilian-Canadian professor who were responsible for planning, coordination, implementation and evaluation of this course. These professors as an organizing team representing each of the participating institutions, intensively reviewed the course proposal (pedagogical activities, workload, participants, dissemination, registration and evaluation) established their contribution as responsibilities, and articulated discussions with university authorities about the signing of international scientific cooperation agreements. Such agreements are currently in the process of being implemented in the form of multi-institutional international scientific cooperation between these four universities.

Coordinators’ actions were underpinned by understanding that internationalization advances nursing science and were guided by a benchmark of critical and emancipatory education,¹⁰ both in local and global contexts. Upon this foundation, the coordinators mapped out issues of responsiveness and possibilities for joint action. The work schedule was made possible in meetings through digital media, as well as by individual contact, using the instant messaging service. These structures and technologies were already installed in universities, as well as personal equipment pre-existed at no additional cost.

Among the resources mapped were the successful results of projects implemented by the Brazilian-Canadian professor at Brazilian universities since 2018 that had enabled the student mobility of a Brazilian PhD student, with funding from the Emerging Leaders in the Americas Program (ELAP; https://www.educanada.ca/scholarships-bourses/can/institutions/elap-pfla.aspx?lang=eng) to the Canadian university and seven Canadian undergraduate students with funding from the Mitacs Globalink Research Award; (https://www.mitacs.ca/en/programs/globalink) to universities in the Midwest region.

Some challenges were faced despite the positive, intense, and fruitful work, which was supported by the motivation of the coordinators, the support of the four universities involved, the Canadian funding obtained, the structural resources, and the logistics. Among these challenges included the limited financial resources of the Brazilian host universities for emerging activities, the challenge of reviewing knowledge which had already assimilated and established as new and innovative, and the uncertainties for the acceptance of this transformation by the course participants.

The excellent work dynamics, with participative leadership methods, has allowed us to verify, since the beginning of the coordination meetings, that the physical distance was not impeding. This has broken the barrier of spatial distance through the optimization of accessible online technologies. In this way, the conjuncture has driven the transmutation of ideas into actions for the implementation of the work process with minimum cost in the host universities through the use of existing infrastructures, such as classrooms and administrative and operational support.

RESULTS

The Brazilian-Canadian professor, as course coordinator, selected the conceptual bases to be adopted and requested the confirmation of these bases by the Brazilian teachers. After this confirmation, the course was designed to include three conceptual perspectives to allow participants to expand knowledge and redesign the understanding of health literacy as a multidimensional component for health promotion. The basis was based on Freire’s pedagogy of critical awareness, including the use of evocative objects¹⁰ and on international publications by authorities on the topic,^11-13 including one specifically targeted to low- and middle-income countries.¹³

This process was facilitated by this professor, who, being from Brazil, understood how communications between sectors of Brazilian universities and cultural forum actions happen. This aspect cannot be classified as determinant, but it allowed issues to be solved with time optimization. The planning of the course began with the creation of the methodological material, which was led by a Brazilian professor who was a specialist in community health as part of her post-doctoral fellowship which was supervised by the Brazilian-Canadian professor at the Canadian university. After establishing the content to be explored in the community health literacy course, three international reference documents for the topic^13-15 were identified, and they were freely translated from English to Portuguese by both professors in Toronto. Next, the other professors of the team undertook the linguistic and semantic revision of the translated material. The translation of the three documents was sent by e-mail to the participants; it was assumed that the translation would allow for isonomy in accessing the information. This strategy sought to activate awareness about the theme, as well as to stimulate the formation of arguments based on appropriate reference.

The course was taught with a 30-hour class load in each city and 10 hours of extra-class activities; the total audience was 63 participants, three of whom were nurses, who came from the states of Ceará and Maranhão, amplifying the capillarity of the course. The attendance in class and in independent activities was 100%, fulfilling the criteria for receiving the certificate of completion of the course. This course also counted with the participation, of a researcher affiliated to REBRALS, a nursing faculty of another university in the Midwest region. The both professors’ cooperation in the classroom was productive because they contributed knowledge about quantitative and qualitative research in the area of community, family and individual health literacy in the Brazilian and international context. Both taught the course, jointly, in the three cities.

In the implementation phase of the course, the classes were participative and used tools for interaction, such as applications/websites, which allowed immediate verbal or digital feedback. Among the applications, the use of Poll Everywhere (https://www.polleverywhere.com/), for example, showed the similarity or not of concepts on health literacy through word clouds. In addition, a question quiz was used through Kahoot (https://kahoot.com/): “What is the fundamental material resource for teaching in health? What kind of innovation do professionals have access to work in health education? What type of teaching provides greater learning in working with the user? How much of the health knowledge that the population possesses can influence their ability to make conscious decisions? What is needed for individual initiatives to promote health to be institutionalized in health services?” These questions were intended to guide discussions and emphasize aspects to be strengthened on site. These moments provided an opportunity for the group to participate by sharing ideas and were not focused on evaluating the participants.

It should be noted that, in the implementation of the course, at each meeting between participants, there was the intention for intellectual provocation using individual and group exercises (participant-participant and participant-teacher). This culminated in the creation of a conceptual map about the application of the health literacy knowledge in their professional contexts, stimulating innovation in projects and ways of doing and, therefore, in the way of being a nurse educator-promoter of health. Participants aligned learning complex concepts of health literacy with the multidimensional perspective because some had confused, until then, the meaning of health literacy with alphabetization in health, due to the literal translation of the words in Portuguese, or even with health education. When participants demonstrated the transposition of the theory into their practices, the professors in classroom were able to make sure that the meaning and its possibilities were appropriated. Thus, concepts embedded with theoretical or conceptual complexity were clarified, demonstrating the gained consciousness of new tools to understand one's own practice.

The results obtained with the online immediate evaluation of the online course sought the intentions¹⁶ of participants to change their practices due to learning acquired in the course; changes were considered as expected and indicated that the pedagogical objectives were fully achieved. However, it was in the classroom where unexpected results revealed the social impact of the learning experience achieved. An outstanding result was the collective expression of awareness of the complexity inherent to global health and health promotion, and community health literacy was perceived as a key tool for global nursing and elevation of the populations' quality of life. Through interactions with participants and considering the results of the course evaluation, the professors, who were still in dialogue with the local team in each university where the course was implemented, could identify another potential impact. This impact was that the course would provoke the debate on curricula of nursing programs in public and private universities, and urge them to focus on encouraging the potential for their students to become part of an emerging and differentiated category of future health educators.

The unexpected results included: the participants' interest in creating projects that would include community health literacy in education in the services for nurses residing in a university hospital; a manager who will implement the concept in their work plans at the administrative level, in a State Secretary of Health (Secretaria Estadual de Saúde); and a group of graduate students who will organize a scientific event to discuss community health literacy in the Unified Health System (Sistema Único de Saúde) reproducing the pedagogical activity offered by the course in the debate activity.

Other intentions to replicate the course were expressed in different contexts of practice and education, of which the enthusiasm to continue the collaboration between participants to create and implement other educational initiatives stands out. We were also surprised by immediate expressions of intention from some participants to apply to master and doctorate programs to conduct research on health literacy. The participants, who were direct supervisors of undergraduate students, expressed plans to integrate the concept in their pedagogical approaches, especially a nursing educator linked to a private college, who declared she felt confident to participate in a working group already implanted in the college where she teaches to update the curriculum in that institution. Another relevant result was the dialogue about future actions of the participants after their affiliations as members of REBRALS.

As planned, one product of the course related to scientific production: four participants requested assistance from the professors as scientific advisors to write research projects for their applications to graduate programs. Both professors stimulated actions for scientific production as related to lectures’ contents, resulting in the acceptance of two abstracts submitted by them and, also, two others, by participants in international conferences. Two other abstracts were prepared by the participants for national congresses, but their submissions were temporarily suspended due to the events postponing. Continuing the dissemination of the results of this international cooperation, the coordination team published a manuscript in a Brazilian peer-reviewed journal¹⁷ and submitted a manuscript to an international journal. Additionally, the Brazilian-Canadian professor participated as an external examiner of a master's committee on the subject of health literacy and advised a PhD student on the submission of an application to ELAP, indicating the continuous flow of internationalization.

In addition, due to the pandemic context, the application of a project by the Canadian faculty to Global Affairs Canada for a second edition of this course was postponed to 2023, with a previously confirmed partnership with the Federal Universities of Piauí, Maranhão, Tocantins, Goiás and Jataí. The objective will also be to offer the course in a complementary way to the interinstitutional PhD activities at the Federal Universities of Pernambuco and Goiás with their collaborators in the North and Northeast regions.

DISCUSSION

This experience confirmed the possibility of knowledge transfer in health with immediate potential to rethink nursing educational practices in health promotion. The scarcity of financial resources to subsidize professional training courses like this can be circumvented by innovative and creative use of available resources, ensuring the generation of academic, political, and social impact. The strengthening of collaborative networks among Brazilian universities has, in turn, strengthened the national inter-university partnership in the area of community health literacy. This experience built upon the internationalization work plan among the partner universities.

The course updated the participants' knowledge, “reconceptualizing” community health literacy for their practice, from the perspective of partnerships, availability, potentialities, opportunities and resourcefulness. The knowledge generated by the course revealed the complexity of actions to promote community health literacy due to the invisibility of nurses as national leaders, resulting from their under-optimization in terms of increasing the evaluation of service quality based on evidence and innovations to produce the desired impacts.

The greatest lesson learned was that internationalization strategies must prioritize simplicity and agility in administrative procedures to use time productively and promote freedom to overcome budget and financing constraints. At the same time, it is expected that the availability of incentive programs for student¹⁸ and professional mobility will be restored. In terms of social impact, we identify that nursing professionals’ recognition of the transforming potential of their educational actions in the field of community health is still incipient in their consciousness. Therefore, other international educational initiatives may contribute to the understanding of the outdated emphasis on the dogmatic force of individual action of nurses for their action targeting a population group. Therefore, focus can shift to the collective when it comes to advocacy for the development of clientele autonomy.

It is believed that the 63 participants of the course make up a critical mass on critical mass on community literacy. Thus health literacy. Thus, it is hoped that the desire to become multiplying agents of this knowledge will lead them to assume local, regional, and national leadership to replicate the course in its total or adapted form. In general, it is recommended that the course be reproduced in other modalities and with diverse clientele including the on-line format, which is free, to reach distant regions and democratize the access to professional development, training and updating, as well as in secondary and tertiary health institutions to increase the extension of family and individual health literacy in the context of clinical practice. It is also recommended that the course be subject to partnerships with: Education Boards for the development of individual health literacy for children and young people in the school context; associations and societies of specialist nurses, so that this concept is consolidated in innovative actions to promote health in specific contexts where the quality of life is under risk of compromise; and Secretary of Justice, to update the knowledge of the nursing team caring for individuals in situations of liberty deprivation.

Other recommendations refer to new opportunities for initiatives and projects in the context of internationalization. The course's professors recognized the potential for mobilization through dialogues on career interests, research, and in view of academic orientation moments with students and faculty in partner universities in this project. As for graduate nursing students interested in short-term research internships, it is necessary to invest existing educational resources in public universities for the acquisition of advanced reading, writing and conversation skills in foreign languages (German, Spanish, French, English, Japanese, Mandarin, among others) so that they can compete in international programs. For undergraduate students, it is recommended that nursing educators establish a strategic program for identifying and investing in emerging intellectual talent, so that such students can also prepare to apply for international scholarships, being a prerequisite the requirement of a general average academic achievement of over 80%.

The internationalization of nursing education and research must be strategically planned in collaboration with students to review how much they can contribute to building a new generation of knowledge-producing nurses.¹⁹ This action plan for internationalization can be applied in the short, medium and long term, with goals that can be inspired by the acronym FAST²⁰ in a new conceptual proposal for managing large organizations. In this acronym, F means that goals need to be Frequently discussed for constant monitoring in order to make sure that one is on the right track with the review of gradual progress in addition to reassessing the allocation of resources and prioritizing initiatives to be implemented. The A represents Ambitious, because their aspects are known to be difficult to achieve, but not impossible. S stands for Specific goals, by highlighting crucial points, always seeking clarity of what is intended. T stands for Transparent goals, for the public openness of the goal achievement process, that is, the shared vision within the academic-scientific nursing community. It is recommended, therefore, that undergraduate and graduate students, as part of the contingent of human resources needed for such processes, be partners in the elaboration, implementation, and evaluation of internationalization plans.

This approach could allow Brazilian nurses to compete on an equal footing in calls for proposals from sources of funding for teaching and research from high-income countries that aim to invest in the human capital that exists in middle and low-income countries. For this reason, the Brazilian nursing programs are invited to see, from now on, their students as bridges between members of the global nursing scientific community. In the present project, it is necessary to emphasize that Canadian students are the target of university initiatives of internationalization with experimental learning, which allows them to connect with other international researchers. Inevitably, faculty would also be a priority group to increase their level of foreign language knowledge.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

This international cooperation has made possible both the exchange of innovative knowledge to overcome challenges and the scientific interaction between Brazilian universities and the Canadian university. The optimization of resources was a priority, with the Brazilian-Canadian faculty alleviating limitations related to cultural specificity. It is suggested that other nursing professors based in foreign universities be mobilized for internationalization with optimization of financial resources. Within the perspective of graduate studies and the instability of funding for science, access to alternative sources of funding by international agencies should be stimulated. These sources can be found with the expansion of work ties, aiming at the internationalization of teaching and research in Brazilian nursing, in order to increase the quality of practice in community health literacy and other areas.

Finally, the implications for practice of this successful experience relate to the possibility of inspiring other refresher courses in academia and health services, driving the internationalization of Brazilian and foreign institutions. As well, it is necessary to rethink the necessary mobilization and optimization of human and financial resources clearly in line with the context and plans for internationalization of research, teaching, and promotion of excellence of professors and students. However, institutional measures for the implementation of the internationalization policy are required to be widely discussed within the university administration and its different departments.

ACKNOWLEDGMENTS

To Dr. Estela Maria Leite Meirelles Monteiro (Universidade Federal de Pernambuco), for her support in implementing the community health literacy course for nurses. Bridget Miller for editing the English version.

• FUNDING

  Fundação de Amparo à Pesquisa do Distrito Federal, Brasília, Brazil. Nº 23106.019016/2019-21 (Post-doctoral scholarship). Global Affairs Canada, Government of Canada. GAC-2019.

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Edited by

ASSOCIATE EDITOR

Antonio José Almeida Filho

Publication Dates

• Publication in this collection
  31 Mar 2021
• Date of issue
  2021

History

• Received
  09 July 2020
• Accepted
  29 Sept 2020