The Toronto Addis Ababa Academic Collaboration in Nursing: Living the Concept of Counterparts

A 2010 Lancet Commission on global higher education for the health professions called for institutional and instructional reforms worldwide in order to keep pace with pressing global health care needs. Among their many recommendations is an awareness of the value of international collaboration to enhance educational quality. In this article, we reflect on our experience of building such a collaboration in nursing. Using the concept of counterparts as articulated by DeSantis (1993; 1995), we describe the highlights as well as the lessons of our work together in developing the research component of the Masters of Science in Nursing (MScN) at Addis Ababa University in Ethiopia. We extend DeSantis’ (1995) emphasis on roles in the relationship for understanding what constitutes success in international collaborations. Beyond identifying roles and responsibilities, our story calls attention to the value of cultivating relationships in which interdependence, mutuality, and issues of reciprocity are at the fore.


Introduction
This paper tells a story of our partnership as nursing educators in Addis Ababa, Ethiopia and Toronto, Canada. As part of the broader Toronto Addis Ababa Academic Collaboration (TAAAC) between Addis Ababa University (AAU) and University of Toronto (UofT), we have come to be known as TAAAC-Nursing. We began with a shared commitment to strengthening the capacity of Ethiopian nursing leaders to undertake research, advance clinical practice, and influence health policy. There are many facets to this decade long partnership. In this paper we focus on just one: the cooperative development of the research component of the AAU Masters of Science in Nursing (MScN). We consider the concept of counterparts (DeSantis, 1993;1995) in light of our initial goals, key activities, and outcomes of the program. The lessons we learned along the way also provide insight into how a counterparts model for international collaboration in nursing education can be extended.
Bender A, Aga F, Demissie A, Cherie A MedEdPublish https://doi.org/10.15694/mep.2016.000124 Page | 2 The Context According to the World Bank (2015), Ethiopia has experienced rapid economic growth in the past decade and such continued growth may position it well to become a middle income country by 2025. However at the same time, the burden of illness and the need for accessible health services remains high for the country's estimated population of over 92 million (Central Statistical Agency, 2013). The government has been making great strides in addressing these challenges, including in the area of higher education for health professionals.
Several reports have highlighted the need to make higher education more available and accessible in sub-Saharan Africa, along with the challenges in doing so (Bloom et al., 2006;Montanini, 2013;World Bank, 2008). African universities struggle with such issues as faculty shortages, academic quality and relevance, limited research capacity, and financial strains. Despite such challenges, most African governments, including Ethiopia, have increased their commitment to higher education, recognizing its key role in social and economic development (Mugimu, 2009). Although this commitment has resulted in ever increasing numbers of students attending university programs, these students are challenged by significant resource constraints and inadequate support for research (Montanini, 2007). Challenges for faculty are also significant in terms of support for developing their research capacity and scholarship.
The education of health professionals presents a unique situation within these broader circumstances because graduates must be prepared for hands-on clinical practice as well as research in the health sector (Kabiru et al., 2010). A Lancet Commission articulated this situation more thoroughly (Frenk et al., 2010), arguing that health professions education has not kept pace with the realities of health (and healthcare) in the 21 st century global context. They highlight the particular challenges of "rapid demographic and epidemiological transitions" related to disease, ongoing "glaring" inequities across countries, and increasingly complex and expensive health systems (p.1923). The report offers a framework for instructional and institutional reforms. Strengthening resources for education, particularly through faculty development, is one of their six recommendations to bring about instructional reform (p.1924). In nursing specifically, roles for leaders in education, research, and health policy and planning are increasing, and such positions require postgraduate preparation (Redman, 2007). Such is the case in Ethiopia. The dramatic shift from diploma to degree level nursing education in the universities over the past 15 years has created a pressing demand for nurse educators with scholarly skills in addition to expertise as clinicians. There are approximately 35 BSc nursing programs in the country (20 in public universities; 15 in private colleges). Most faculty members in university programs are hired immediately upon graduation from their own BSc programs and then are sent for postgraduate education often after a year of teaching. Addis Ababa University is tasked with the postgraduate preparation of nursing faculty for most of the other universities.

TAAAC-Nursing
In 2005  profession. The professional associations continued to work together on regulatory issues while we focused our AAU-UofT efforts on postgraduate curriculum support.
The Ethiopians identified research, particularly qualitative methodologies, as our first priority. We reviewed curriculum and set objectives, and in 2010 our action plan was underway. Over the next three years, we completed seven teaching blocks with the aim of strengthening students' critical appraisal and research skills in qualitative research methodologies through course development and teaching, student assessment, and thesis support. We held a secondary objective of supporting AAU faculty members in fulfilling their role as thesis advisors and in developing their own scholarship.
The research component of the Master's program is comprised of a required Nursing Research Methodology course and a second-year thesis project that includes an approved proposal, ethics review, data collection and analysis, and a final written report and oral defense. We understood our attention to enhancing the content, activities, and assignments in the program as an important contribution to developing research capacity in the profession. In the Ethiopian context, nurses are typically viewed as care providers only, and in terms of research are often relegated to the role of data collector for others' studies. Part of the purpose of preparation at the postgraduate level is equipping them to take part in research studies as investigators, which in turn positions them to lead nursing-focused research in the country.
We carried out all our activities cooperatively, with the priorities and direction being set by the Ethiopians. Canadians travelled to Addis Ababa twice a year engaging in classroom teaching, thesis mentoring, and strategic networking. The classroom teaching involved didactic lecture, small group discussions, and other participatory exercises. One class exercise in which students brainstormed research topics and then helped one another to refine to a researchable question was new for them and particularly well received. In terms of student assessment, a new assignment involving a systematic literature search and new exam questions were created for the course. Additionally, a 2012 teaching trip coincided with a trip by TAAAC Librarians so a full day seminar and practice lab was arranged for all students and interested faculty. They were introduced to the WHO HINARI database and systematic literature searches. The practice lab with its direct step-by-step guidance in using HINARI was also well received by students.
There was also ongoing thesis support, onsite and by distance. During initial trips, time was reserved for individual thesis meetings to trouble-shoot literature search challenges, answer questions regarding qualitative data analysis, and give feedback on proposals and final report writing. However, only a few students wanted to meet individually. Most preferred small group and class meetings in order to learn from each other's questions. So thesis support became a more collective and mutual learning endeavour.Canadians adjusted subsequent schedules to lead additional optional research seminars, including the introduction of mock proposal defenses for those interested. Students were open and ready to share their project ideas and dilemmas. We discussed research questions and related literature, feasibility challenges, tips for writing, and the Ethiopian context in relation to their research interests. Learning was reciprocal between the Canadian teachers and Ethiopian students in these conversations.
Email communication was offered as another way to provide thesis support between trips. In the first year, a UofTbased e-mentor was matched with each of the 36 students and their faculty advisors. However, by the following year, only six pairs had maintained regular communications. On the suggestion of one student, social media came to play a helpful role. A private Facebook group for the Class of 2012 was created and a second for the Class of 2013 soon followed. The first author acted as administrator of the groups and a few other international teachers joined the groups. Guidelines were set regarding the purpose as primarily a space for professional sharing. Information was exchanged related to health and nursing research, policy, and practice as well as the challenges of their own research projects. Even now, years after graduation, several members continue to use these group pages to share about their academic careers and other points of nursing interest.
There were several planning and evaluation meetings throughout the program that were vital for formative evaluation, logistical coordination, and visioning for continued collaboration.
Our communication with each other and the students in this regard was critical because program plans prior to the Canadians' arrival in Addis Ababa always changed after arrival. Course schedules, content, and teaching strategies were renegotiated according to changes in programming demands and infrastructure challenges. More formally, at the end of each trip, students completed course evaluations and we met for program review meetings in which we identified teaching accomplishments, challenges, and any trip objectives that were not met. This in turn guided planning for the next trip. The Canadian involvement in the research course came to an end in 2013. The research course continues with the added qualitative methodology lecture materials and readings, the systematic literature search assignment, and exam questions. It is taught entirely by AAU faculty.

TAAAC-Nursing as a Relationship of Counterparts
DeSantis (1993) borrowed from international and economic development literature to adapt the concept of counterparts for understanding international nursing partnerships in higher education. While her work is more than 20 years old, its underlying assumption holds true for present-day nursing education initiatives between low-income countries and high-income countries. That is, that successful international development rests on creating a pool of skilled and knowledgeable personnel "to assure the ongoing viability of the resulting program" (DeSantis 1993, p.283). Her emphasis was on strengthening capacity and relationship building as integral to the sustainability of educational programming. Key features of the counterpart relationship are translatable in present day partnerships like TAAAC-Nursing.

The Counterparts Relationship Defined
Simply defined, counterparts are people from a"donor group (foreign experts)" and "recipient group (host country nationals)" who collaborate from the start on carrying out their shared program plan (DeSantis, 1993, p.283). As Canadian and Ethiopian counterparts in TAAAC-Nursing, we exhibited what she identifies as 'donor' and 'host' skill sets respectively: Canadians primarily brought theoretical knowledge, technical competence, teaching expertise, and cultural sensitivity; while Ethiopians primarily brought sophisticated skills of cultural translation and facilitation for knowledge transfer and exchange in the local context (at professional, institutional, and social levels).These categories of skill must not be rigidly interpreted as prescriptive or exclusive of each other. Rather as DeSantis (1995) points out, real-life collaborations involve a blurring of all forms of expertise across counterpart groups. Notably however, the relationship is asymmetrical in terms of type and degree of knowledge shared and we all recognized the asymmetry of our relationship from the start.We were always learning from each other. In this way, our experience reflected the "two-way collegial exchange" that characterizes a successful counterpart relationship (DeSantis, 1995, p.206). Although Ethiopians were academically well prepared in research methods generally and experienced in quantitative methods specifically, Canadians provided additional experience and expertise in qualitative research. Similarly, although Canadians had experience in international partnerships, Ethiopians provided the necessary cultural translation expertise in adapting our plan for the local context. Four factors have been said to determine the success of international nursing programs. While DeSantis (1995, p.199) acknowledged them as worthy goals, she also argued that the process-oriented nature of the counterparts relationship must be considered in meeting them. We reflect on them here in light of our TAAAC-Nursing experience.

Four Factors for Success
Factor #1The program addresses the needs, available resources, and developing potential of the host counterpart: A formal agreement is the first step in ensuring this goal. We laid out roles and responsibilities for our respective universities as well as the deliverables and timeframe. The existing capacity of the AAU faculty responsible for the research course was an important starting point for co-developing the new content and sharing the teaching of the course. A key lesson learned regarding resources was the challenge of providing meaningful mentoring across distance. As information technology continues to advance in Ethiopia, online options for mentoring ought to be explored as part of curriculum planning. Specifically the success of using social media as a means of communication warrants closer (and careful) attention.
Factor #2 Socio-political, cultural, and economic factors likely to affect the success and sustainability of the program are addressed in the planning stage: Recognizing and addressing such factors was vital for our partnership. It was especially important for Canadians to understand the academic context of AAU and the MScN program requirements. It was also significant that Ethiopian counterparts taught Canadians about the nursing context more broadly. Herein lies another lesson learned. No doubt, carefully addressing as many socio-cultural factors as possible in the planning stage helps to ensure that programs will run successfully. The more obvious preparations like teaching plans and course materials were shared and discussed by email; and Toronto-based TAAAC orientations covered information on language, currency, climate, and general customs etc. However, the nuances of such factors as the organization of the Ethiopian health system, the hierarchical nature of interprofessional relationships in healthcare, and the job market and locations of practice for MScN graduates could not be fully understood by Canadians in the planning stage alone or even in a single teaching trip. This kind of understanding can only truly come with time.
Similarly, the Ethiopians support of Canadians in meeting daily living needs during the teaching trips highlights a point about the social context. Although Canadians were well-travelled and planning included pre-trip information about things like accommodation, means of communication and transit, the actualities of negotiating and navigating such in the busy city of Addis Ababa also became part of our relationship-building beyond the planning stage. This social dimension is often left out of literature about professional partnership programs, perhaps deemed irrelevant or unimportant. But it bears noting here. Ethiopians assisted Canadians with these details of daily life in their already heavy workloads and often outside of paid worktime. While deeply appreciative, Canadians were also fully aware of the added burden that our presence created in this regard. Counterparts must know that even with the most thorough planning, success also requires staying open in later stages to adjusting expectations, programmatic and otherwise, as mutual understanding evolves. see this as a loftier vision. While being an every-present ideal to work toward, developing to one's 'full potential' as an individual is a subjective experience and a program's full potential can be open to wide variations in interpretation. Furthermore developing potential, or strengthening capacity, is also inextricably linked to resources and issues of access and equity. In TAAAC-Nursing we experienced the challenge of this ideal. Our original secondary aim of supporting Ethiopian faculty development was at best only minimally met. We began with a focus on the faculty advisor-student relationship and co-mentoring of individual students. However, largely due to competing workload demands for AAU faculty, direct connections between Canadians and AAU faculty advisors did not form as originally intended. Instead, Canadians continued mentoring students separately as described previously and always with the understanding that students made all thesis decisions with their advisors. And, the Ethiopian co-teacher of the research course was left to become the channel of communication between Canadians and advisors. In recognizing this gap she suggested that rather than focusing on student mentoring, we shift to a kind of faculty mentoring; helping them to build their own research knowledge and skill and support their scholarship. In this, Canadians were reminded that postgraduate education in nursing was still a recent change in the country and many faculty advisors were new to the academic world of teaching and research at the postgraduate level. So seminars on writing for publication, systematic literature review, and tips on preparing applications for doctoral programs were developed and built into the schedule for all subsequent trips. However, the same challenges in making connections regarding student thesis support also prevented attendance at these seminars. How best to translate ideas for meaningful faculty development into action is a continuing question. We learned that if the host counterparts are to be able to develop their full potential as leaders in nursing research, scholarship, and postgraduate education, the complexities of workload burden in a resource-constrained context must be carefully considered in planning and throughout the collaboration.

Conclusion
In our TAAAC-Nursing experience, the success of a counterparts relationship is not so easily judged by a neat set of criteria alone. For example, networks of new relationships also emerged for us with other TAAAC teams and University of Toronto affiliates as well as midwifery teachers from Queens University in Belfast Ireland. Where does such networking fit in evaluating the success of international collaborations? Like DeSantis (1995), we emphasize the relationship in understanding success in international collaborations. Diverging from her focus on roles and responsibilities though, our experience calls attention to the value of cultivating relationships in which interdependence, mutuality, and issues of reciprocity are recognized over time and addressed together. Indeed aiming to negate the 'donor' counterpart's role and to actualize the full potential of 'host' counterparts ought to be at the heart of any capacity development endeavour. But we argue that it doesn't end there. Relationships evolve, needs shift, and the partners' roles change as different plans for working together take shape.