Ex-post Evaluation

1.1 Background of the Project

In 1992, the Government of Sri Lanka requested the Government of Japan for grant aid and technical assistance as a measure to overcome the shortage of nurses in Sri Lanka. The shortage of nurses has been a serious constraint faced by the health service sector in Sri Lanka. Once the nature of the assistance was ascertained, the Japanese Government responded by providing a 5 years technical cooperation commencing in October 1996.

1.2 Project Overview

This project aimed to improve nursing education in the National School of Nursing, Sri Jayawardenapura (NSN SJ) and make it a model nursing school with the intension of diffusing quality nursing education to other nursing schools. The initial phase of the project consisted mainly of the preparatory work necessary to establish a model school. The second and third phases were systematically planned to extend outputs achieved at the model school to develop the entire nursing cadre in the country.

(1) Overall Goal

To make an effort to improve both the quantity and quality of nurses in Sri Lanka by:

• Fulfilling the regular nursing cadre in Sri Jayawardena Hospital in 5 years
• Increasing the total number of number of nurses in Sri Lanka in 5 years

(2) Project Purpose

To establish a model school of nursing and to improve quality of basic nursing education in Sri Lanka.

(3) Outputs

1) Effective educational activities were conducted in the newly established nursing school, National School of Nursing, Sri Jayawardenapura (NSN SJ).

2) Capacity of teaching staff at 11 nursing schools in the country including NSN SJ was improved.

3) Managerial aspects of the 11 nursing schools were improved under the influence of NSN SJ.

4) Clinical undergraduate training of nursing was improved with the guidance of NSN SJ.

5) Equipment, instruments, and other related teaching materials, which were provided by the Project, were properly utilized at all nursing schools.

(4) Inputs (at the time of Project Termination)

Japanese side:

Sri Lanka side :

3.1 Summary of Evaluation Results

(1) Impact

i) Achievement of Overall Goal

The overall goal of increasing the quantity of nurses has been achieved partially and NSN SJ provides 50% of students from each batch of trained nurses to the Sri Jayawrdenepura Hospital (SJH). However due to the absence of recruiting and training a batch of student nurses in 2003, SJH currently suffers from a severe shortage of nurses. The shortage of nurses in SJH in 2001 was 31.6% but in 2005 the shortage has increased to 40.7%.

ii) Other Positive Effects

Knowledge updates, technological transfers and lessons exchanged through workshops and seminars during the "Project" period continue to motivate nursing staff in their professional development.

Due to the facilities available at NSN SJ, midwifery students are also been trained in the nursing school.

Teaching material developed during the "Project" period are still being utlised.

iii) Other Negative Effects

There has been no significant increase in the capacity of teaching staff since the termination of the "Project". The number of seminars and workshops attended by the Tutorial Staff is much less than during the Project period.

The increased intake of midwifery students has resulted in a corresponding decrease in the number of nursing students recruited.

Increasing annual intakes of students without adequate increases in infrastructure facilities, teaching staff, equipment etc have resulted in deterioration in the standards of nursing education.

(2) Sustainability

i) Technical Aspects

Although annually more nurses are being trained, there is no corresponding increase in infrastructure, human and material resources resulting in overcrowded classrooms, inadequate equipment and teaching staff adversely affecting the quality of training.

Whilst most of the equipment provided by the "Project" is still in use, some lie idle due to lack of knowledge on how to use them. Maintenance systems are weak due to lack of local service agents to service and provided spare parts.

ii) Financial Aspects

Poor planning and coordination in allocation and implementation of funds means that funds do not always go where they are needed. Funds are not allocated directly to the Principals but are routed through the Directors of the respective Teaching Hospitals who decide how the funds are to be allocated.

iii) Organizational Aspects

Policies, including the number of student nurses to be recruited, are made at the Ministry of Health through the annual training calendar. However there is no corresponding training calendar for Tutor training resulting in recruitment of teaching staff after the recruitment of the nursing students, adversely affecting the Teacher : Student ratios. Policy decisions are often influenced by other factors such as shortages in the availability of paramedics which impact on decisions such as finalization of annual nursing student numbers.

3-2. Factors that have promoted Project

(1) Impact

Sri Lanka has obtained an additional nurses training centre which is contributing to increasing the total number of nurses being trained annually and helping in achieving the objective of 35,000 trained nurses by 2010.

The curricula introduced by the "Project" is continued with very little revision and uniformity in training is ensured in all schools of nursing by using the same manuals.

(2) Sustainability

The Project's main contribution is providing a stimulating learning environment through the use of education methods, such as workshops and seminars, and materials, which motivate teaching staff towards professional development and higher education. Most of NSN SJ staff are now graduates or undergraduates with more having applied for the B.Sc. in Nursing degree program.

The "Project" has contributed significantly in improving computer literacy amongst teaching staff with teaching staff at NSN SJ having much higher levels of computer literacy than the School of Nursing, Kurunegala.

3-3 Factors that have Inhibited the Project

(1) Impact

Whilst the original intention of the "Project" was to contribute 50% of the nursing staff of SJH, SJH currently suffers from a severe shortage of staff largely due to the absence of a student intake in 2003. This was a result of a change in the administrative bodies that took some time to make decisions.

The increase in Teacher : Student ratios has resulted in less attention during practical lessons which in turn affects clinical exposure of students. As a result failure rates at final examinations are nearly 45% island-wide.

(2) Sustainability

The "Project" intended that NSN SJ have a maximum of 300 female students. However male students have also been enrolled in addition to two batches of midwifery students. Midwifery training has always been conducted by nursing schools affiliated to Teaching Hospitals with the support of Nursing Tutors. As a result classrooms and hostel facilities are overcrowded and equipment and facilities stretched, overall affecting the quality and standards of nurses training.

3-4. Conclusions

The overall goal of increasing the quantity of nurses has been achieved during the "Project" period. The main contribution made by the "Project" is the establishment of a conducive learning environment which stimulates learning and professional development. With support given by the "Project" through NSN SJ, the number of M.Sc. qualified nurses in Sri Lanka has increased from 6 to 26. The "Project" has given a new direction to nursing education through the introduction of new teaching materials and equipment.

However, the original intention of standardization of nursing education has not been maintained after the termination of the "Project" and has affected the current standard and quality of education at NSN SJ.

Although many nurses are now B.Sc and M.Sc qualified they have no opportunity to participate in decision-making as policy decisions continue to be made by non-nursing officials at the Ministry of Health.

3-5. Recommendations

Curricula should be reviewed periodically. It is recommended that Principals and Directors get involved in developing or reviewing curriculum, clinical practices and enrollment of students.

The high failure rates at the final examination needs to be addressed. Whilst it is necessary to meet increased cadre requirements, the quality of training should not be compromised.

Proper assessments of classroom facilities, equipment, availability of tutorial staff and practical environment in the hospitals, hostel and other support services should be undertaken before enrolling students. Ministry of Health should be encouraged to make necessary policy decisions to ensure a lower Teacher : Student ratio.

Suitably trained technicians and service agents should be appointed by the Ministry of Health to carry out regular maintenance of equipment to ensure that students obtain the full benefit of the equipment provided.

More opportunities for professional development should be encouraged to develop capacities of nursing personnel in order to develop them as good administrators and to be able to participate in planning and decision-making.

3-6. Lessons Learnt

A proper policy on recruitment of teaching staff to support the proper functioning of nursing schools should be established. Appropriate policy support is necessary for the impact of the project to be sustained.

Arrangements for maintenance and operation of equipments should be made so that equipments provided can be utilized fully.

Increased cooperation and coordination between Hospitals and Schools is required so that nurses who are under in-service training can spare sufficient time for necessary training. Increased communications and better understanding between teachers and nurses should be encouraged to improve cooperation between ward staff and students.