Study setting design

This study was conducted at the Lao Friends Hospital for Children (LFHC), a no-cost tertiary pediatric referral facility located in Luang Prabang, northern Laos. According to UNICEF estimates, the pediatric population in Laos is approximately 2.8 million; however, LFHC is one of only two dedicated pediatric hospitals in the country. Since opening its doors in 2015 with an outpatient clinic and inpatient wards, LFHC has expanded to provide a full range of specialized services, including surgery, neonatal, emergency, and critical care, a developmental clinic, and a thalassemia program. Annually, the hospital now serves more than 45,000 children from across northern Laos and has provided access to care for over 200,000 patients in the first ten years of operations. LFHC continues to train a growing workforce of Lao physicians and nurses, many of whom are new to pediatric specialty care.

Study design

This study used a multi-method program evaluation design to assess the LFHC Pediatric Nursing Training Program implemented between 2015 and 2019. The evaluation incorporated three complementary data sources: a review of program curriculum and associated documents, an electronic survey of expatriate clinical mentors, and semi-structured interviews with former nurse leaders at LFHC. This approach allowed for triangulation of perspectives from individuals involved in program implementation, mentorship, and leadership.

Due to travel restrictions imposed during the COVID-19 pandemic, all evaluation activities were conducted remotely using online platforms. Surveys were designed and distributed through REDCap, a secure web-based platform for managing online surveys and databases. [14,15]. The survey remained open for participation from December 15, 2020, to February 1, 2021. Semi-structured interviews with former nurse leaders were conducted via Zoom between February and March 2021. Program curriculum documents and related materials were reviewed concurrently using a shared secure cloud-based document platform.

Evaluation and theoretical framework

The evaluation was guided by the Context–Input–Process–Product (CIPP) evaluation framework, which is commonly used to assess educational and health workforce development programs. The CIPP framework supported a structured examination of the LFHC Pediatric Nursing Training Program by assessing the program context, the inputs used to support program development including curriculum and mentorship structures, the processes through which training and mentorship activities were implemented, and the perceived outcomes and sustainability of the program.

In addition, Madeleine Leininger’s Transcultural Theory of Nursing informed the conceptual understanding of cross-cultural mentorship and training within the program [16]. This theory emphasizes the importance of cultural awareness and culturally congruent care when working with diverse populations. The framework has been widely used in global health and resource-variable settings to guide culturally responsive health workforce development. Incorporating this theoretical perspective supported interpretation of how cultural context influenced mentorship relationships, training adaptation, and program sustainability.

Sample selection and recruitment

Participants were purposively selected based on their direct involvement in the LFHC Pediatric Nursing Training Program between 2015 and 2019. Two participant groups were included: former LFHC clinical mentors and nurse leaders.

Clinical mentors were international nurse volunteers who served in mentorship roles, providing didactic education, bedside clinical teaching, and support to Lao nurses in applying knowledge to practice. Mentors also contributed to curriculum development and competency evaluation. Contact information for clinical mentors who volunteered at LFHC between 2015 and 2019 was obtained from the LFHC Human Resources Department and the Nursing Director. An introductory email was sent to potential participants explaining the study and inviting them to complete an online survey via a REDCap link.

Nurse leaders consisted of expatriate staff who worked at LFHC in Nursing Director or Nursing Educator roles. These individuals played a critical role in adapting and sustaining the program within the local context while residing in Laos and contributed to curriculum design, mentorship structures, and leadership development. All eligible nurse leaders were invited by the research team, in collaboration with the current Nursing Director, to participate in semi-structured interviews. Invitations were sent via email, asking interested participants to select an interview date and time.

This purposive sampling strategy ensured representation from individuals who directly designed, implemented, and guided the program, capturing perspectives central to evaluating its outcomes and sustainability.

Data tools and collection

Data collection occurred simultaneously through a review of curriculum documents, a REDCap survey, and through semi-structured interviews over a four-week period. The LFHC Nurse Training Program curriculum and other relevant documents were gathered and reviewed to evaluate the following themes: program design, program objectives, training schedule, and the content of the program. Attention to the train-the-trainer model and cultural relevance was also noted.

The LFHC Clinical Mentor Survey consisted of three sections and was distributed in January 2021 to all expatriate nurses who participated in the clinical mentorship program from 2015 to 2019. The first section gathered information about participants’ nursing background, clinical experience prior to LFHC, and any prior experience working abroad. The second section focused on the expatriate nurses’ perspectives regarding the clinical skill set of the Lao staff nurses during their time at LFHC. Ratings were done based on recall of past experiences of direct observation. The final section provided an opportunity for self-reflection on the expatriate nurses’ contributions to the training process, specifically in clinical mentoring and cultural competence. A pilot test was conducted to enhance the face and content validity of the survey before it was distributed. All the data collected from the survey were imported via REDCap into a Microsoft Excel spreadsheet for analysis.

Interviews with former nurse leaders were scheduled at a time convenient for each participant. The interviews were conducted via Zoom and were recorded with the participants’ permission. Each interview was designed to last approximately one hour. The LFHC Program Evaluation Interview Guide was used for the semi-structured interviews and consisted of 14 questions (Fig 1). Two questions collected demographic data about the nurse leaders, while the remaining 12 questions focused on evaluating the program. These questions encouraged participants to reflect on their role in facilitating the LFHC Nurse Training Program. To ensure content and face validity, the interview guide was tested by the research team at Vanderbilt University. The interviews were recorded by the interviewer and submitted to Trint Ltd., an online high-quality and secure transcription service, to be transcribed [17].

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Fig 1. Interview Guide.

https://doi.org/10.1371/journal.pone.0349226.g001

Data analysis

Data collected from the electronic REDCap survey were analyzed using descriptive statistics. Demographic variables were summarized as frequencies and percentages. Likert-scale responses were analyzed in Microsoft Excel using built-in functions (AVERAGE and STDEV) to calculate mean scores and standard deviations. For the qualitative component, interviews were audio-recorded, transcribed verbatim, and anonymized prior to analysis. Data were examined using thematic analysis informed by grounded theory methodology. Coding was performed manually by two members of the research team, followed by review with the Principal Investigator. The coding process involved open coding to identify initial concepts, axial coding to organize these into categories, and iterative refinement of emerging themes and subthemes. Discrepancies were resolved through consensus meetings, and an audit trail of coding decisions was maintained. Triangulation across coders and data sources enhanced credibility, and cross-validation of findings strengthened the rigor and trustworthiness of the analysis.

Ethical considerations

This study received ethical approval from the Institutional Review Board (IRB) at Vanderbilt University under exempt (non-research) status (Protocol #202298). Additional approval to proceed with the study was granted by the Lao Friends Hospital for Children (LFHC) Research Committee following review of the study protocol. Participation in the study was entirely voluntary. Consent was implied through the completion of surveys and participation in interviews or focus groups, with participants informed of their right to withdraw at any time without penalty. No financial incentives or compensation were provided. All data were anonymized to safeguard confidentiality, and results are reported in aggregate to protect participant identity. Audio recordings of interviews and focus groups were obtained only with consent and remain securely stored, with assurance of non-disclosure beyond the research team.

Curriculum documents review

The curriculum documents were stored on a privately accessed Microsoft OneDrive, with access controlled by the head of information technology at LFHC. The OneDrive contains organized folders, including audits, competency, courses, curricula, English vocabulary list, exams, in-services, medication safety, emergency simulations, nursing orientation, students, and training records, each with several subfolders. A review of the curriculum documents revealed thorough and well-organized record-keeping of clinical courses taught as part of the education and training programs since 2016. The training documents and PowerPoint presentations for each course were easily accessible in their designated subfolders. Lesson plans clearly outline the targeted learning objectives for each course, along with the associated evaluation methods, which include hands-on activities and group exercises. The clinical competency evaluations were clearly documented for each nurse at LFHC, but the schedule for student reassessment or evaluation was unclear. It was also unclear if there was testing to measure expatriate nurses’ understanding of the content that they were teaching.

LFHC clinical mentorship survey

The LFHC Clinical Mentorship Survey was distributed to 148 former nursing volunteers who served from 2015 to 2019. Sixty-seven of the volunteers responded and completed the survey in full for a return rate of 45%.

Expatriate nurse demographics.

The first section of the survey focused on the demographics and work history of expatriate nursing volunteers (Table 1). A total of 67 survey responses were analyzed, revealing participation across all years of the Pediatric Nursing Training Program’s initial operation. The majority of respondents volunteered in 2017 (n = 19) and 2018 (n = 17), with additional participation in 2015 (n = 6), 2016 (n = 10), and 2019 (n = 15). Regarding the duration of service at LFHC, most respondents (64.2%) reported volunteering for two to six months (n = 43). Seventeen volunteers (25.4%) stayed for one month, five (7.5%) for six months to one year, and two (3%) for more than one year.

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Table 1. Demographics of Participants: LFHC Clinical Mentorship Survey.

https://doi.org/10.1371/journal.pone.0349226.t001

The participants represented a diverse range of countries, with the majority identifying as Australian (n = 21), American (n = 19), British (n = 11), Canadian (n = 8), or New Zealander (n = 3). Additional countries of origin included Italy (n = 2), Spain, Portugal, and Denmark (n = 1 each). Notably, 41 respondents (61%) had prior experience in resource-variable settings (RVS).

Forty-eight expatriate volunteers (71.5%) identified as bedside registered nurses, while others reported varied roles, including clinical nurse specialists (13.4%, n = 9), nurse educators (11.9%, n = 8), advanced practice nurses or nurse practitioners (7.5%, n = 5), operating room nurses (4.5%, n = 3), professors at university nursing schools (3%, n = 2), and nurse anesthetists (1.5%, n = 1).

Participants also had diverse clinical backgrounds. More than half (50.7%, n = 34) had experience in pediatric wards. Other areas of clinical experience included emergency departments (38.8%, n = 26), pediatric-specific emergency departments (27.3%, n = 25), pediatric critical care (26.9%, n = 18), pediatric clinics (20.9%, n = 14), neonatal intensive care (17.9%, n = 12), and pediatric hematology and oncology (16.4%, n = 11).

The respondents varied in their years of clinical nursing experience before joining LFHC: 17 (25.4%) had one to five years of experience, 22 (32.8%) had five to ten years, nine (13.4%) had 10–15 years, and 19 (28.4%) had over 15 years of experience.

Evaluation of the content of the training program.

In the second section of the LFHC Clinical Mentorship Survey, participants rated the Lao nursing staff on 14 skills using a Likert scale ranging from one to five where one referred to insufficient knowledge and being unable to complete the skill, while five referred to completing competence in knowledge and skill and being able to help support others (Table 2). The mean (standard deviation) of the clinical skill set rated by the participants in 2015 was 2.8 (0.4). Over the course of five years, the mean increased to 3.5 (0.5) in 2019. The greatest changes in mean scores between 2015 and 2019 were starting an IV live (1.1), recognition of a patient having a seizure (1), application of weight-based medication dosing (0.8), and application of appropriate respiratory support for hypoxia (0.8). The smallest change in mean scores was seen in the knowledge of normal vital signs for age (0.2), performing a 12-lead ECG (0.3), and recognition of a patient in respiratory distress or failure (0.3).

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Table 2. LFHC Clinical Mentorship Survey: Nursing Clinical Skill Data by Year.

https://doi.org/10.1371/journal.pone.0349226.t002

LFHC Program evaluation: Semi-structured interviews

Key findings

The LFHC Nursing Training Program led to a notable improvement in the Lao nurses’ clinical skillset, as consistently emphasized by both clinical mentors and nurse leaders. In addition to strengthening procedural competence, the program facilitated a shift toward more advanced forms of clinical reasoning and problem-solving. Participants described how nurses began to move beyond rote memorization toward applying knowledge in practice, asking questions, and critically engaging with patient care. These changes reflect a transition from task-based nursing to a more holistic and critical thinking approach to clinical practice.

A central factor in this development was the adaptation of the curriculum to the Lao context. By eliminating materials designed for high-income countries and customizing training to reflect local epidemiology, cultural practices, and available resources, the LFHC team ensured that the curriculum was both accessible and relevant. Such contextualization is consistent with literature on global health education, which emphasizes that externally imported curricula, without adaptation, often fail to achieve meaningful practice change [18–20]. The WHO ETAT course, for example, was attempted at LFHC but was reported to be of limited value without curriculum adaptations due to its misalignment with Lao nursing practice and cultural norms.

The program’s combined strategy of structured didactic sessions and hands-on clinical mentorship was another key contributor to success. Bedside mentorship created a feedback loop in which nurses could immediately apply knowledge, receive guidance, and reflect on practice. Nurse leaders noted that mentorship also facilitated psychosocial support, helping Lao nurses develop confidence and autonomy in their roles. Importantly, the clinical mentorship model was not static. Over time, it shifted from broad support of all staff to more targeted mentorship for junior nurses, allowing for efficient use of mentor expertise.

A further strength of the LFHC program was its investment in sustainability through leadership development. The modified train-the-trainer approach was pivotal in building long-term capacity. By the second year, a Lao nurse was identified as a future educator, and by 2019, this nurse was independently teaching the core curriculum. This not only ensured program continuity but also signaled a critical shift in power and ownership from expatriate staff to Lao leadership. In qualitative accounts, this transition was described as a turning point that inspired other nurses to aspire to leadership roles. Such findings align with global evidence that local leadership and peer-to-peer teaching are essential for enduring health system strengthening [21].

Perhaps most importantly, the LFHC experience demonstrated that cultivating critical thinking among nurses is possible even in traditionally rote-based educational systems. Through compassionate teaching, interactive learning strategies, and culturally sensitive mentorship, Lao nurses developed the ability to analyze clinical situations, anticipate complications, and contribute actively to care planning. This represents a substantial departure from historical models of nursing education in LMICs and highlights the potential for global nursing initiatives to drive pedagogical change.

Taken together, the findings of this evaluation underscore the importance of three interdependent elements in global nursing capacity building: contextual adaptation of curricula, integration of bedside mentorship, and investment in leadership through train-the-trainer strategies. The LFHC model demonstrates that when these elements are combined, nurse training can advance beyond technical skill acquisition to foster critical thinking, confidence, and sustainable leadership.

Volunteer perspectives and bidirectional learning

A significant finding from this study was the difference in the mean scores reflecting volunteers’ knowledge of the role of Lao nursing before and after participation at LFHC (3.5 vs. 4.4). This increase demonstrates that international clinical mentors not only contributed to the strengthening of Lao nurses’ clinical skills but also deepened their own understanding of the cultural, clinical, and leadership roles of local nurses. This highlights the reciprocal nature of the program, in which mentorship fostered bidirectional learning and exchange. Importantly, it underscores the value of cultural humility in cross-cultural partnerships, as volunteers gained greater awareness of the Lao context and the complexities of nursing practice in a resource-variable setting. Such findings reinforce the importance of designing global mentorship initiatives as bidirectional learning opportunities that promote both local capacity building and the professional development of international collaborators.

Implications for global nursing education

The evaluation of the LFHC Nursing Training Program provides important lessons for nursing education in resource-variable settings. First, the findings reinforce that standardized, externally developed training programs may not achieve their intended outcomes without meaningful cultural and contextual adaptation. Efforts to implement global curricula such as WHO’s ETAT course highlight this limitation, as the program was perceived as misaligned with local needs and practices. In contrast, the LFHC model demonstrated that tailoring content to reflect local learning styles, language, and health system realities can lead to measurable gains in both clinical skills and critical thinking.

Second, the integration of bedside mentorship alongside didactic learning proved critical. This aligns with growing evidence that experiential learning models are particularly effective for bridging knowledge-to-practice gaps in nursing. Mentorship not only improved technical competencies but also fostered professional identity and autonomy, qualities that are central to the advancement of nursing as a profession globally. For nurses in Laos, who traditionally trained in hierarchical and didactic systems, the opportunity to engage in dialogue, ask questions, and apply critical reasoning marked a transformative educational shift.

Finally, the study underscores the importance of embedding cultural humility into global nursing education. Expatriate mentors and educators at LFHC recognized that success depended on listening to Lao nurses’ perspectives, respecting local practices, and adapting pedagogical approaches accordingly. This emphasis on cultural humility rather than cultural competence promoted a spirit of mutual learning and helped establish trust, which was repeatedly highlighted in interviews as central to the program’s success.

Sustainability and leadership development

A key contribution of the LFHC program was its explicit focus on sustainability. Too often, nursing education initiatives are limited by dependence on external trainers or short-term funding. In contrast, LFHC prioritized developing local leadership capacity through a modified train-the-trainer approach. By the second year of the program, a Lao nurse was formally identified as an educator, and within three years, they assumed independent responsibility for delivering the curriculum. This transition not only secured the program’s continuity but also elevated the professional role of nurses within the hospital.

Leadership development extended beyond the formal educator role. Qualitative findings revealed that exposure to mentorship and responsibility inspired many Lao nurses to envision themselves as leaders in their units. Several participants reflected that the program encouraged them to mentor junior colleagues, set standards for practice, and advocate for patient care improvements. These findings echo global nursing literature that emphasizes the link between local leadership and sustainable improvements in care quality.

The emphasis on sustainability also offers insights for broader health systems. By empowering Lao educators and fostering critical thinking among staff, the LFHC program contributed to resilience during crises, including the COVID-19 pandemic, when international travel restrictions severely limited expatriate support. In this way, the program illustrates how investments in LMIC nursing leadership can buffer against system shocks and promote long-term independence from external aid.

Broader global health implications

Beyond the context of LFHC, this evaluation contributes to the discourse on how global partnerships can advance health equity. It illustrates the value of bi-directional learning, where expatriate mentors adapted their teaching to local contexts while simultaneously learning from Lao nurses about culturally grounded care practices [22]. Such partnerships advance not only technical skills but also relational capacity, which is critical for sustainable health system strengthening.

Furthermore, the LFHC experience provides a replicable model for other low- and middle-income countries seeking to strengthen pediatric nursing education. The combination of contextualized curricula, mentorship, and leadership development could be adapted for various clinical areas, from emergency and critical care to maternal and newborn health.

Strengths and limitations of the study

The strengths of this project include strong engagement and participation from nursing leadership at LFHC. The clinical mentorship survey achieved a response rate of 45 percent, and six of the seven former nurse leaders from LFHC participated in semi-structured interviews, ensuring a broad representation of leadership perspectives. The use of a mixed-methods approach further strengthened the evaluation by helping to mitigate potential deficiencies and biases associated with reliance on a single method [23].

This study also has several limitations. A primary limitation was recall bias, as participants were asked to reflect on past work experiences [24]. Social desirability bias may have further influenced responses, particularly in relation to sensitive topics such as leadership and training effectiveness. The COVID-19 pandemic imposed additional challenges, including the absence of a standardized, validated survey tool, reliance on online technologies with varying levels of internet connectivity, and the inability to conduct in-person data collection. Lastly, due to travel restrictions during the pandemic, feedback from Lao staff could not be incorporated, limiting the inclusion of their perspectives, which are essential for a comprehensive evaluation of the LFHC Pediatric Nursing Training Program. Despite these limitations, the study provides critical insights into the development, implementation, and sustainability of pediatric nursing education and mentorship at LFHC, offering lessons that may be transferable to education program development in similar resource-variable settings.

Recommendations for further research

This study provides evidence for new approaches to building and evaluating sustainable and culturally relevant nursing training programs in resource-variable settings. The lessons learned from this project can inform future capacity-building initiatives by highlighting techniques to identify potential barriers early and equipping program developers with the tools necessary to ensure program success.

Future research is needed in several areas. First, further studies should evaluate the long-term outcomes of train-the-trainer models, particularly regarding how they influence nurse retention, leadership development, and patient outcomes. Second, research should focus on refining methods for integrating cultural humility, which must be a central component of any cross-cultural partnership, into training curricula. This includes evaluating how cultural humility practices affect learner engagement, mutual respect, and the sustainability of acquired skills. Third, there is a need for comparative studies examining how different mentorship models, such as in-person, virtual, or hybrid, affect knowledge translation and practice change across resource-variable contexts. Finally, involving nurses in LMIC’s perspectives, which were limited in this study due to COVID-19 restrictions, will be crucial for gaining a more comprehensive understanding of training needs, effectiveness, and sustainability.