Prevalence and determinants of overweight and obesity among preschool-aged children from migrant and socioeconomically disadvantaged contexts in Montreal, Canada.

Among migrant and socioeconomically disadvantaged preschool-aged children followed in social perinatal primary care services in Montreal, Canada, we estimated the prevalence of overweight/obesity and identified determinants of body mass index z-score (zBMI) at 4-5 years old. We conducted a retrospective cohort study using electronic medical records of 275 child-mother dyads followed from birth to 4-5 years. Anthropometric measures and established maternal, perinatal and child risk factors for childhood obesity were examined. Age- and sex-specific zBMI at 4-5-years were computed and categorized according to WHO standards. Linear regression with model averaging was used to identify early life factors associated with zBMI. At 4-5 years, children's weight status was classified as underweight (1.5%), normal weight (69.7%), at-risk-of-overweight (19.2%), overweight (6.9%), and obesity (2.7%). Primiparity (0.51, 95% CI 0.24; 0.78), higher birthweight (1.04, 95% CI 0.70; 1.37), accelerated weight gain in the first year of life (0.21, 95% CI 0.13; 0.31), and introduction to solid foods before 6 months (0.89, 95% CI 0.42; 1.36) were associated with a higher zBMI, while less than high school education (-0.50, 95% CI -0.95; -0.05) and higher gestational age (-0.14, 95% CI -0.21; -0.05) were associated with lower zBMI at 4-5 years. Overweight/obesity is prevalent among preschool-aged children from migrant and socioeconomically disadvantaged contexts and is associated with known risk factors. Future research is needed to better understand the role of social perinatal primary care services in promoting optimal weight gain among children living in contexts of vulnerability.

Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low- and lower-middle-income countries: a rapid scoping review.

BACKGROUND: Policymakers and program developers in low-and lower-middle-income countries (LLMICs) are increasingly seeking evidence-based information and guidance on how to successfully develop and implement continuing professional development (CPD) systems. We conducted a rapid scoping review to map and synthesize what is known regarding the development, implementation, evaluation and sustainability of CPD systems for healthcare professionals in LLMICs. METHODS: We searched MEDLINE, CINAHL and Web of Science. Reference lists were screened and a cited reference search of included articles was conducted. Supplementary information on the CPD systems identified in the articles was also identified via an online targeted grey literature search. English, French and Spanish literature published from 2011 to 2021 were considered. Data were extracted and combined and summarized according to country/region and healthcare profession via tables and narrative text. RESULTS: We included 15 articles and 23 grey literature sources. Africa was the region most represented followed by South and Southeast Asia and the Middle East. The literature most often referred to CPD systems for nurses and midwives; CPD systems for physicians were frequently referred to as well. Findings show that leadership and buy-in from key stakeholders, including government bodies and healthcare professional organizations, and a framework are essential for the development, implementation and sustainability of a CPD system in a LLMIC. The guiding framework should incorporate a regulatory perspective, as well as a conceptual lens (that informs CPD objectives and methods), and should consider contextual factors (support for CPD, healthcare context and population health needs). In terms of important steps to undertake, these include: a needs assessment; drafting of a policy, which details the regulations (laws/norms), the CPD requirements and an approach for monitoring, including an accreditation mechanism; a financing plan; identification and production of appropriate CPD materials and activities; a communication strategy; and an evaluation process. CONCLUSION: Leadership, a framework and a clearly delineated plan that is responsive to the needs and context of the setting, are essential for the development, implementation and sustainability of a CPD system for healthcare professionals in a LLMIC.

Transnational prenatal care among migrant women from low-and-middle-income countries who gave birth in Montreal, Canada.

OBJECTIVES: There is little research examining transnational prenatal care (TPC) (i.e., prenatal care in more than one country) among migrant women. Using data from the Migrant-Friendly Maternity Care (MFMC) - Montreal project, we aimed to: (1) Estimate the prevalence of TPC, including TPC-arrived during pregnancy and TPC-arrived pre-pregnancy, among recently-arrived migrant women from low- and middle-income countries (LMICs) who gave birth in Montreal, Canada; (2) Describe and compare the socio-demographic, migration and health profiles and perceptions of care during pregnancy in Canada between these two groups and migrant women who received no TPC (i.e., only received prenatal care in Canada); and (3) Identify predictors of TPC-arrived pre-pregnancy vs. No-TPC. METHODS: The MFMC study used a cross-sectional design. Data were gathered from recently-arrived (< 8 years) migrant women from LMICs via medical record review and interview-administration of the MFMC questionnaire postpartum during the period of March 2014-January 2015 in three hospitals, and February-June 2015 in one hospital. We conducted a secondary analysis (n = 2595 women); descriptive analyses (objectives 1 & 2) and multivariable logistic regression (objective 3). RESULTS: Ten percent of women received TPC; 6% arrived during pregnancy and 4% were in Canada pre-pregnancy. The women who received TPC and arrived during pregnancy were disadvantaged compared to women in the other two groups (TPC-arrived pre-pregnancy and No-TPC women), in terms of income level, migration status, French and English language abilities, access barriers to care and healthcare coverage. However, they also had a higher proportion of economic migrants and they were generally healthier compared to No-TPC women. Predictors of TPC-arrived pre-pregnancy included: 'Not living with the father of the baby' (AOR = 4.8, 95%CI 2.4, 9.8), 'having negative perceptions of pregnancy care in Canada (general experiences)' (AOR = 1.2, 95%CI 1.1, 1.3) and younger maternal age (AOR = 1.1, 95%CI 1.0, 1.1). CONCLUSION: Women with more capacity may self-select to migrate during pregnancy which results in TPC; these women, however, are disadvantaged upon arrival, and may need additional care. Already-migrated women may use TPC due to a need for family and social support and/or because they prefer the healthcare in their home country.

Religion, support and self-care experiences: A qualitative descriptive study with Indonesian adults with the chronic disease living in Montreal, Canada.

AIM: To explore and describe the chronic illness self-care experiences of Indonesian immigrants living in Montreal, Canada and to gain a better understanding of how religion and support shaped these experiences. DESIGN: Qualitative description. METHODS: Data were collected from January to March 2020 via semi-structured interviews. Eight men and women participated. The data were thematically analysed. RESULTS: Major themes identified were (1) religion, (2) being helpful to others, (3) family support, (4) transnational family support, (5) community support and (6) being in Indonesia versus Canada. Religion and faith were sources of motivation for self-care and provided guidance and strength to heal and accept the illness, mainly through the practice of prayer. 'Being helpful to others' (collectivism), including aiding others to avoid getting sick or giving 'health tips', and also just generally taking care of family also contributed to overall well-being. Spouses were the main source of assistance with disease monitoring and management and health maintenance, whereas support from the Indonesian community was minimal and mostly consisted of informational and social support. Transnational relationships with family members in Indonesia, however, provided an additional means for obtaining emotional support, advice and access to traditional medicines. Overall, there was little expectation that family or the community offer or provide support with self-care. These low expectations may partially be explained by the different cultural and social contexts in Canada compared with Indonesia. CONCLUSION: Religious, cultural, social and family factors may be carried over from the home country and/or may be altered post-migration, and this may impact how Indonesian immigrants with chronic illness engage in self-care. IMPACT: Cultural factors (collectivism, traditional medicines), religious beliefs and support networks, both locally and transnationally should be assessed and considered during care to better support and promote self-care among immigrants living with chronic diseases. PATIENT OR PUBLIC CONTRIBUTION: Two Indonesian community organizations facilitated recruitment and data collection.

Social Isolation, Loneliness and Health: A Descriptive Study of the Experiences of Migrant Mothers With Young Children (0-5 Years Old) at La Maison Bleue.

Background: Migrant women with young children, including asylum seekers and refugees, have multiple vulnerability factors that put them at increased risk of social isolation and loneliness, which are associated with negative health outcomes. This study explored the experiences of social isolation and loneliness among migrant mothers with children aged 0-5 years as well as their perceptions on possible health impacts. Methods: A qualitative descriptive study was conducted at La Maison Bleue, a non-profit organization providing perinatal health and social services to vulnerable women in Montreal, Canada. Recruitment and data collection occurred concurrently during the COVID-19 pandemic, between November and December 2020. Eleven women participated in individual semi-structured interviews and provided socio-demographic information. Interview data were thematically analyzed. Results: Migrant women in this study described social isolation as the loss of family support and of their familiar social/cultural networks, and loneliness as the feelings of aloneness that stemmed from being a mother in a new country with limited support. Multiple factors contributed to women's and children's social isolation and loneliness, including migration status, socioeconomic circumstances, language barriers, and being a single mother. Women expressed that the COVID-19 pandemic exacerbated pre-existing experiences of social isolation and loneliness. Mothers' experiences affected their emotional and mental health, while for children, it reduced their social opportunities outside the home, especially if not attending childcare. However, the extent to which mothers' experiences of social isolation and loneliness influenced the health and development of their children, was less clear. Conclusion: Migrant mothers' experiences of social isolation and loneliness are intricately linked to their status as migrants and mothers. Going forward, it is critical to better document pandemic and post-pandemic consequences of social isolation and loneliness on young children of migrant families. Supportive interventions for migrant mothers and their young children should not only target social isolation but should also consider mothers' feelings of loneliness and foster social connectedness and belongingness. To address social isolation and loneliness, interventions at the individual, community and policy levels are needed.

A scoping review on the measurement of transnationalism in migrant health research in high-income countries.

BACKGROUND: Migrants commonly maintain transnational ties as they relocate and settle in a new country. There is a growing body of research examining transnationalism and health. We sought to identify how transnationalism has been defined and operationalized in migrant health research in high income countries and to document which populations and health and well-being outcomes have been studied in relation to this concept. METHODS: We conducted a scoping review using the methodology recommended by the Joanna Briggs Institute (JBI). We searched nine electronic databases; no time restrictions were applied. Studies published in English or French in peer-reviewed journals were considered. Studies were eligible if they included a measure of transnationalism (or one of its dimensions; social, cultural, economic, political and identity ties and/or healthcare use) and examined health or well-being. RESULTS: Forty-seven studies, mainly cross-sectional designs (81%), were included; almost half were conducted in the United States. The majority studied immigrants, broadly defined; 23% included refugees and/or asylum-seekers while 36% included undocumented migrants. Definitions of transnationalism varied according to the focus of the study and just over half provided explicit definitions. Most often, transnationalism was defined in terms of social connections to the home country. Studies and measures mainly focused on contacts and visits with family and remittance sending, and only about one third of studies examined and measured more than two dimensions of transnationalism. The operationalization of transnationalism was not consistent and reliability and validity data, and details on language translation, were limited. Almost half of the studies examined mental health outcomes, such as emotional well-being, or symptoms of depression. Other commonly studied outcomes included self-rated health, life satisfaction and perceived discrimination. CONCLUSION: To enhance comparability in this field, researchers should provide a clear, explicit definition of transnationalism based on the scope of their study, and for its measurement, they should draw from validated items/questions and be consistent in its operationalization across studies. To enhance the quality of findings, more complex approaches for operationalizing transnationalism (e.g., latent variable modelling) and longitudinal designs should be used. Further research examining a range of transnationalism dimensions and health and well-being outcomes, and with a diversity of migrant populations, is also warranted.

Challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries: a scoping review with a gender lens.

BACKGROUND: International and migrant students face specific challenges which may impact their mental health, well-being and academic outcomes, and these may be gendered experiences. The purpose of this scoping review was to map the literature on the challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, with a gender lens. METHODS: We searched 10 databases to identify literature reporting on the challenges, coping responses and/or supportive interventions for international and migrant nursing students in college or university programs in Canada, the United-States, Australia, New Zealand or a European country. We included peer-reviewed research (any design), discussion papers and literature reviews. English, French and Spanish publications were considered and no time restrictions were applied. Drawing from existing frameworks, we critically assessed each paper and extracted information with a gender lens. RESULTS: One hundred fourteen publications were included. Overall the literature mostly focused on international students, and among migrants, migration history/status and length of time in country were not considered with regards to challenges, coping or interventions. Females and males, respectively, were included in 69 and 59% of studies with student participants, while those students who identify as other genders/sexual orientations were not named or identified in any of the research. Several papers suggest that foreign-born nursing students face challenges associated with different cultural roles, norms and expectations for men and women. Other challenges included perceived discrimination due to wearing a hijab and being a 'foreign-born male nurse', and in general nursing being viewed as a feminine, low-status profession. Only two strategies, accessing support from family and other student mothers, used by women to cope with challenges, were identified. Supportive interventions considering gender were limited; these included matching students with support services' personnel by sex, involving male family members in admission and orientation processes, and using patient simulation as a method to prepare students for care-provision of patients of the opposite-sex. CONCLUSION: Future work in nursing higher education, especially regarding supportive interventions, needs to address the intersections of gender, gender identity/sexual orientation and foreign-born status, and also consider the complexity of migrant students' contexts.

Les politiques publiques affectant négativement les familles demandeuses d'asile avec des jeunes de 0 à 5 ans au Québec.

In 2019, 30,615 asylum claims were made in Quebec, representing almost half of the claims made in Canada. Asylum-seeking families with young children (0 to 5 years) represent a significant proportion of this population. Canada, as well as Quebec, have a responsibility to protect asylum seekers and to ensure that public policies promote health and well-being, especially among children. However, certain existing public policies exclude asylum seekers and are negatively affecting families. This commentary seeks to raise awareness among all those involved in policymaking, especially decision-makers, regarding asylum-seekers and three policy domains that are contributing to poverty, social isolation, and reduced access to care among asylum-seeking families with young children. These include the lack of eligibility for child benefits, the limited access to affordable daycare, and barriers to accessing family doctors. Consequently, both parents and children suffer impacts to their health and well-being. We are calling on our governments to assume their responsibilities and eliminate these inequities, and to ensure that the health of asylum seekers is considered in all policies.

RéSUMé: En 2019, 30 615 demandes d'asile ont été traitées au Québec, ce qui représente presque la moitié des demandes au Canada. Les familles avec des enfants de 0 à 5 ans représentent un pourcentage important de cette population. Le Canada ainsi que le Québec ont l'obligation de protéger les demandeurs d'asile et d'assurer que les politiques publiques soient favorables à la santé, surtout chez les enfants. Toutefois, certaines politiques publiques actuelles excluent les demandeurs d'asile et affectent négativement les familles. Ce commentaire vise à sensibiliser l'ensemble des acteurs impliqués dans l'élaboration des politiques publiques, surtout les décideurs politiques, sur des enjeux concernant trois domaines de politiques publiques qui contribuent à l'isolement social, à l'appauvrissement et à un accès réduit aux services de soins pour les familles demandeuses d'asile avec de jeunes enfants. Ceux-ci incluent la non-éligibilité aux allocations familiales, l'accès difficile aux garderies à prix abordables et les difficultés à obtenir des services d'un médecin de famille. En conséquence, les parents et les enfants subissent des impacts sur leur santé et leur bien-être. Nous demandons à nos gouvernements d'assumer leurs responsabilités et d'éliminer ces inégalités, et d'assurer que la santé des demandeurs d'asile soit prise en compte dans toutes les politiques.

Factors associated with cyber-victimization among immigrants and non-immigrants in Canada: a cross-sectional nationally-representative study.

OBJECTIVES: There is a paucity of research on patterns of cyber-victimization in minority groups, including immigrants. This study aimed to identify individual, interpersonal and contextual characteristics associated with cyber-victimization among immigrants and non-immigrants. METHODS: We drew on nationally representative data from adolescents and adults in the Canadian General Social Survey on victimization (2014). We used multivariable logistic regression to identify potential factors associated with cyber-victimization in the last 12 months, stratified by immigrant status and sex. RESULTS: Among 27,425 survey respondents, the weighted prevalence of cyber-victimization in the last 12 months was 2.1% among immigrants and 2.3% among non-immigrants. Cyber-victimization rates differed significantly by sex among immigrants (2.8% for males vs. 1.4% for females), but not among non-immigrants (2.1% for males vs. 2.4% for females). While most other factors associated with cyber-victimization were similar for immigrants and non-immigrants, there were pronounced associations of past child maltreatment (adjusted prevalence odds ratio [aPOR] 4.85, 95% confidence interval [CI] 2.76, 8.52) and residence in an unwelcoming neighbourhood (aPOR 5.08, 95% CI 2.44, 10.55) with cyber-victimization among immigrants that were diminished or absent among non-immigrants. Additionally, sex-stratified analyses among immigrants showed cyber-victimization to be strongly associated with having a mental health condition (aPOR 3.50, 95% CI 1.36, 8.97) among immigrant males only, and with perceived discrimination (aPOR 4.08, 95% CI 1.65, 10.08), as well as being under 24 years old (aPOR 3.24, 95% CI 1.09, 9.60) among immigrant females. CONCLUSIONS: Immigration status and sex were differentially associated with cyber-victimization. Findings support the salience of a social-ecological perspective and gender-stratified analyses to better elucidate complex pathways linking cyber-victimization to potential gender-based health inequities among immigrants.

Self-Care Experiences of Adults with Chronic Disease in Indonesia: An Integrative Review.

We conducted a literature review to document what is known regarding the self-care experiences and various influencing factors among adults living with chronic disease in Indonesia, from the perspective of those living with the illness. We searched CINAHL and Google Scholar to identify peer-reviewed research focused on men and/or women living with a chronic disease (the most prevalent) in urban or rural settings in Indonesia. Using a "Self-Care of Chronic Illness" framework as a guide, information on self-care experiences and how various factors influence these experiences, was extracted and synthesized. Nine studies were included (3 quantitative; 6 qualitative). Self-care involves maintaining well-being through different strategies (e.g., foot hygiene, seeking information/care, praying, diet, resting, and simplifying life), following prescribed treatments, and using traditional remedies. Religion sometimes serves as a means for taking care of one's health (e.g., prayer), or as a source of motivation to self-care, while in other instances, it results in a fatalistic attitude. Which treatments (conventional versus traditional) are sought, it is affected by an understanding of the disease and treatments, which is shaped by beliefs, values, emotions, health literacy, and SES. The literature shows that family, especially women, has a key role in providing support. Community organizations also play an important supportive role, particularly for patients in rural areas. Significant barriers to healthcare include costs and care not being well-adapted to the psychosocial needs and contexts of patients. The literature highlights a disconnection between the self-care experiences and how healthcare and support are delivered. To better support self-care, healthcare professionals should use a personalized approach; however, more research is needed to gain a better understanding of what patients want and expect regarding how religion, beliefs, life circumstances, and the use of alternative therapies should be addressed within the patient-professional dynamic.

Transnationalism and care of migrant families during pregnancy, postpartum and early-childhood: an integrative review.

BACKGROUND: Migrant families' transnational ties (i.e., connections to their countries of origin) may contribute to their hardships and/or may be a source of resiliency. A care approach that addresses these transnational ties may foster a positive identity and give coherence to experiences. We conducted an integrative review to determine what is known about transnational ties and the care of migrant families during pregnancy, postpartum and early childhood. METHODS: We searched 15 databases to identify literature reporting on a health or social program, service, or care experience of migrant families during pregnancy up to age five in a Western country (i.e., Canada, US, Australia, New Zealand or a European country). Information regarding if and how the service/program/care considered transnational ties, and care-providers' perceptions of transnational ties, was extracted, analyzed and synthesized according to transnational 'ways of belonging' and 'ways of being'. RESULTS: Over 34,000 records were screened; 69 articles were included. Care, programs and services examined included prenatal interventions (a mhealth app, courses, videos, and specialized antenatal care), doula support, maternity care, support groups, primary healthcare and psycho-social early intervention and early childhood programs. The results show that transnational ties in terms of 'ways of belonging' (cultural, religious and linguistic identity) are acknowledged and addressed in care, although important gaps remain. Regarding 'ways of being', including emotional, social, and economic ties with children and other family members, receipt of advice and support from family, and use of health services abroad, there is very little evidence that these are acknowledged and addressed by care-providers. Perceptions of 'ways of belonging' appear to be mixed, with some care-providers being open to and willing to adapt care to accommodate religious, cultural and linguistic differences, while others are not. How care-providers perceive the social, emotional and economic ties and/or the use of services back home, remains relatively unknown. CONCLUSION: Significant knowledge gaps remain regarding care-providers' perceptions of transnational 'ways of being' and whether and how they take them into account, which may affect their relationships with migrant families and/or the effectiveness of their interventions. Continued efforts are needed to ensure care is culturally safe for migrants.

Migrant families with children in Montreal, Canada and transnational family support: a protocol for a focused ethnography.

INTRODUCTION: There is a gap in research regarding transnational family support (emotional, practical, spiritual, informational and financial) as a resource for migrant families with children. From the perspective of migrant families and their family back home, the objectives of this study are to (1) identify the types and ways that transnational family support is provided to migrant families in Canada; (2) assess for patterns in the data that may suggest variations in the nature of this support (eg, by migration status, time in Canada, children's ages, family circumstances) and over time and (3) explore the impact (positive and negative) in receiving and providing transnational support, respectively. METHODS AND ANALYSIS: A focused ethnography is planned. We will recruit 25-35 migrant families with children with different migration histories (eg, economic or forced migration from a mix of countries) and family circumstances (eg, single parenthood, families living with extended family, families with children in the home country) living in Montreal, Canada. Families will be recruited through community organisations. Data will be gathered via semistructured interviews. To capture the perspective of those providing support, family members in the home country for each migrant family will also be recruited and interviewed through communication technology (eg, WhatsApp). Data collection will also involve observation of 'transnational interactions' between family members in Montreal and those back home. Data will be thematically analysed and results reported in a narrative form with an in-depth description of each theme. ETHICS AND DISSEMINATION: Ethical approval was obtained from the sciences and health research ethics committee at the University of Montreal. Study results will be shared through traditional forums (publication, conference presentations) and via other knowledge dissemination/exchange activities (eg, 'lunch and learn conferences' and seminars) through the research team's research centres and networks to reach front-line care-providers who interface directly with migrant families.

La Maison Bleue: Strengthening resilience among migrant mothers living in Montreal, Canada.

INTRODUCTION: La Maison Bleue is a community-based perinatal health and social centre in Montreal that provides services during pregnancy up to age five to families living in vulnerable contexts. The study aimed to describe: 1) the challenges and protective factors that affect the well-being of migrant families receiving care at La Maison Bleue; and 2) how La Maison Bleue strengthens resilience among these families. METHODS: We conducted a focused ethnography. Immigrants, refugees, asylum seekers and undocumented migrants were invited to participate. We collected data from November to December 2017 via semi-structured interviews and participant observation during group activities at La Maison Bleue. Data were thematically analysed. RESULTS: Twenty-four mothers participated (9 interviewed, 17 observed). Challenges to well-being included family separation, isolation, loss of support, the immigration process, an unfamiliar culture and environment, and language barriers. Key protective factors were women's intrinsic drive to overcome difficulties, their positive outlook and ability to find meaning in their adversity, their faith, culture and traditions, and supportive relationships, both locally and transnationally. La Maison Bleue strengthened resilience by providing a safe space, offering holistic care that responded to both medical and psychosocial needs, and empowering women to achieve their full potential towards better health for themselves and their families. CONCLUSION: Migrant mothers have many strengths and centres like La Maison Bleue can offer a safe space and be an empowering community resource to assist mothers in overcoming the multiple challenges that they face while resettling and raising their young children in a new country.

Rien ne doit se faire pour eux sans eux : renforcer la participation des demandeurs d'asile, réfugiés et migrants sans statut et des organismes communautaires dans la recherche en santé.

The number of vulnerable migrants in Canada is on the rise. While debates on immigration policies have been at the forefront, there has been little dialogue regarding the health and well-being of refugees, asylum-seekers and non-status migrants despite the significant health inequities that these populations face. In this context, health research that aims to understand migrants' realities, develop appropriate health and social services and policies, and empower these populations, is needed more than ever. Participatory action research (PAR) is one approach for conducting relevant and empowering research with migrants, however it remains underutilized due to inadequate funding, infrastructure and support. PAR addresses real-life challenges, emphasizes collaboration with communities, and involves all stakeholders, including community-based organizations, in the co-construction and implementation of practical solutions. In this commentary, we call for more research with and for migrants, particularly in the form of PAR, as well as for more targeted funding initiatives and research conditions (University, funding agencies) that foster and support this type of research.

The creation and integration of a nurse educator position in two hospitals in Haiti.

BACKGROUND: Continuing education is an integral part of nursing professional development and improving healthcare delivery, but literature on continuing education initiatives in low-resource settings is limited. PURPOSE: To describe the creation and integration of a nurse educator (NE) position in two Haitian hospitals and highlight barriers and facilitators experienced by the NEs in their role. METHODS: Four NEs and three support staff involved in the creation and integration of the NE positions were interviewed. Supplementary data were gathered through participant observation and document review. Data were compiled and summarized. DISCUSSION: NEs were hired to assess learning needs, evaluate skills, train and mentor nurses, and provide ongoing support to assure application of new knowledge. Barriers included lack of specialized training and limited informational resources to develop education activities, role confusion and heavy workload, poor attendance and disparate education needs of nurses, and insufficient hospital resources and support to implement practice changes. Facilitators included previous management experience, peer support, and a perception of being valued by patients and colleagues and making a difference regarding nursing care and patient outcomes. CONCLUSION: The NE is a leadership role and a promising, sustainable initiative for developing the nursing profession in Haiti.