BWH’s First Global Nursing Fellow Returns from Rwanda

Kate Sullivan made fast friends with nurses in Rwanda.

BWH’s first Global Nursing Fellow Kate Sullivan, MSN, RN, CMN, returned earlier this year from Rwanda, where she worked in three Partners In Health (PIH) hospitals for six months. Sullivan has worked for 30 years as a midwife at Brookside Community Health Center and the BWH Midwifery Group in the Center for Labor and Birth. The Global Health Nursing Fellowship was developed jointly by the Department of Nursing and the Division of Global Health Equity to identify contributions of nursing in developing countries and implement effective treatments, provide opportunities for BWH nurses to participate on clinical field rotations around the world and to develop nursing’s role in interdisciplinary care models globally. During the fellowship, Sullivan attended many births, provided feedback to PIH leadership about equipment and staffing needs and advocated for better resources for patients.

In addition to her clinical work, much of her time was devoted to teaching nurses at Kirehe District Hospital, Rwinkwavu Hospital and Burera District Hospital in eastern and northern Rwanda several hours apart by vehicle. Sullivan also held workshops with many attendees coming from ambulatory practices in remote health centers affiliated with these hospitals. Some nurses were dedicated to maternity care, many were generalists with responsibility for periodic rotations into maternity and all were at different levels of proficiency with different levels of interest in learning and practice. Some, Sullivan found, considered themselves experienced nurses whose time and energy was best spent solving practical problems, rather than attending teaching sessions. Others were beginning nurses and enthusiastic about the learning opportunity.

To meet their needs, Sullivan used several different teaching methods with each group to introduce and try to better ensure changes in practice. Below is an excerpt from an executive report of the first Global Nursing Fellow, in which Sullivan reflects on her time teaching, the lessons she taught and the lessons she learned.

And so the lessons, for me, continued…..

Participatory sessions, are considered a hallmark of adult learning, and varied in success, depending on the audience. I made assumptions about how shy Rwandan nurses were, based on past experience with my very first workgroup that I thought could be applied to all Rwandan nurses. These assumptions did not completely apply to other sites, and with other teams. Yet what was applicable was the discomfort experienced while waiting expectantly to hear an answer to a question. It was dangerous to proceed, I learned, without knowing where people were coming from.

“This baby is not breathing: what do we do?”

“Hit him on the bottom!”

“This baby has a slow heart rate and the mother is unable to push strongly – what do we do?”

“Cut a second episiotomy!”

The Focus

Teaching very specific and basic clinical techniques was important within the context of the culture and the needs of the specific group. However, there were some clinical skills that were quite empowering, including eliciting reflexes, evaluating edema, finding a fetal heart rate in early pregnancy, looking for costo-vertebral angle tenderness, doing a breast exam, eliciting a Homan’s sign, catheterizing the umbilical vein, Leopold’s maneuvers, identifying rebound tenderness and guarding.

But most valued by nursing staff—perhaps not surprisingly—was learning to use equipment. Mastering how to use the ambu bag and moving on to understand the anesthesia bag, using the breast pump and doptone, performing manual vacuum aspiration, and, of course, the ultrasound. I was puzzled about this at times. At one point, when we were brainstorming about how to introduce screening for cervical cancer, I tried to find maternity nurses who were interested in learning how to do speculum exams. I was sure that they would jump at the chance, but not one nurse wanted to learn this—it was seen as a doctor’s skill. But when it was offered as the first step in training to do manual vacuum aspiration, it was easily accepted.

Clinical dilemmas were frequent topics: If you start having some suspicion that your patient is having an abnormal labor, is that the time to put in IV access even if access is costly and might not be absolutely necessary? If two patients need you simultaneously - a newborn is not breathing but its mother is bleeding very heavily—whom do you take care of, and whom do you leave aside? If the pediatric ward has borrowed your unit’s oxygen source and you are managing someone with possible fetal distress, how do you get your oxygen back?

Invasive maneuvers often seemed to make many nurses uncomfortable. There was resistance during workshops on postpartum hemorrhage to performing manual removal of the placenta, or bimanual compression—doubts were expressed as to whether these are really safe, feasible or effective. At one point, nurses giggle uncontrollably when we talk about using a ‘vaginal hand’ to elevate the fetal presenting part in the event of cord prolapse. I wonder if it is a nervous prudishness–several of these nurses are nuns–but what actually turned out to cause the utter hilarity was the idea of maintaining this awkward maneuver, in the back of an ambulance that is thrashing from side to side down the world’s bumpiest rock-and-dirt roads.

There is some outright rebellion about one maneuver: injecting oxytocin directly into the uterine muscle, transabdominally, in the event of life-threatening postpartum uterine atony. I watch my colleague Jacklin patiently and gently work through students’ resistance. He leads them to it logically: they give injections into the deltoid and gluteus, no? This is an injection into a muscle, as well. Could direct intramuscular injection work faster than trying to assemble and insert an IV line? Yes, this is clear. Is oxytocin’s effect limited to uterine muscles? Yes, it is. Then, is there any reason not do this? Only nervousness at the newness of it, nurses conclude. We practice with improvised mannequins. I learn so much from his manner.

Rwandan nurses were eager students.

Effective Approaches

One helpful approach involved repetition—mantras in the form of questions and answers. For example, “What is the first sign of shock?” “Why is that the first sign?” “How is adrenalin diluted?” “How fast does the normal baby breathe?”

Answers eventually became singsong, and I hoped the exercise reinforced the importance of having the information at your fingertips.

Laughter also helped so much. I was perfectly happy to clown around to get a point across and became somewhat famous for teaching a waltz rhythm by dancing around the room—an effort to demonstrate the rate and rhythm for ambu-ing a baby during assisted respiration. These nurses later burst out singing “1-2-3” in waltz rhythm at odd moments like having their pictures taken or when they were lining up for lunch, and laughing delightedly.

I learned that incentives were important in Rwanda. Some staff were motivated to learn for the sake of learning, but many operated with specific expectations of return. Easiest to satisfy was the expectation of a certificate documenting training; this is highly valued and respected, and often sought even after a one-hour discussion of a new topic.

The most favored setting for learning was a formal workshop: Rwandan nurses appreciate structured educational sessions and also appreciate the opportunity to leave their workplace to attend a workshop that includes lodging, meals and travel costs. Assignment to these formal, offsite training workshops was a sought-after perquisite, which perhaps 30 percent of staff are awarded.

Financial incentives like meeting or exceeding certain national goals resulted in better reimbursement for health institutions and sometimes in salary bonuses for nursing staff. Activities that could contribute to ‘performance-based financing’ though sometimes seemingly illogical, were favored.

Lessons for the Learner and the Teacher

I’ve struggled with lessons about how to sustain the learning. Every single teacher/trainer probably already knows that if you are really lucky, the lessons will stick.

Even with motivated learners in what seemed like a really effective, interactive, practical session that included a competency demonstration during the session, the learning did not necessarily stick. Staff sometimes remembered they’d had training in something but could not necessarily recall the training points (I have complete sympathy for this problem.) Written texts, or topic-specific wall posters depicting or listing the elements of changed practice were effective as references and reminders, but it’s perhaps universally true that training alone doesn’t guarantee change in a long-established practice or replace this habitual practice.

Approaches that involved the use of written tests (pre and post-tests, self-corrected and then kept as reference material) seemed helpful. Workshops that provided plenty of time for group breakout sessions (as long as these were not dominated by any one individual) seemed to be very helpful following didactic sessions introducing new clinical practices. Group exercises to highlight the specific areas of difference between current and proposed clinical practices were usually pretty lively; it seemed that it was helpful to staff to work through their surprise and/or disbelief together, in a group, before committing to adopting a change in clinical practice.

And follow-through by participating in the daily practice and reinforcing the behaviors—was of course of greatest importance. This is the great strength of the fellowship model: working side by side with nurses in day-to-day practice. Talking about managing shock for example (identifying it, responding efficiently to the emergency, marshalling team resources) is intensely more rich the day a patient has presented in shock than the day the topic occurs in a curriculum. Reviewing an actual clinical presentation in detail, and in discussion deliberately validating the complexity of the nursing—the assessment skills, the critical thinking skills and the communication skills necessary to provide the best possible care for the patient—always represented the most concrete opportunity for real learning.

System Change

I learned a few basics about moving systems toward change: patience, patience, patience. And showing up!

This takes many, many meetings, a lot of discussion to get consensus, and very careful follow-up of any decisions apparently made. A written agenda is helpful for these meetings. However, discussion on many levels—from the most general to the most specific—may take place at any point in the process. You have to be ready to start all over again, perhaps weeks after you believed the change was already implemented. If you do not go to every meeting remotely related to the topic, you might not be aware of revisions in the plan. If things fall apart, you might not be informed.

Some Questions to Consider

The biggest question of all still remains unanswered: How to achieve meaningful change in clinical practice? Tuning in to staff levels of motivation for learning and change—listening for this every day—is certainly fundamental, but beyond this, I have only questions:

Is it always best to ask staff to identify their own learning needs, or to think about areas of practice that seem unsatisfactory to them? In Rwanda this varied in effectiveness mostly by work group and probably due both to level of experience, and to stage of motivation for change.

Is it most effective to find the leaders, or the early adopters, and support them in championing change? This also was variably productive – but six months was probably too short a time to assess this well. And what if the leaders do not support change?

Is it better to work with outcome data to try to identify the drawbacks of the status quo? Or is it better to promote the very specific benefits that change could produce? Emphasize benefits for the patients? For staff? For Rwanda?

Is it important to focus on making the change really easy to adopt into practice and perhaps spark some momentum for change?

Should practice change be incentivized/rewarded? Could establishing consequences for ‘non-change’ be an effective approach? Is personal or emotional reinforcement of change helpful – that is, are staff influenced by a nurse clinical leader or a trainer, who expresses frustration at something that has not changed, or delight and pride at something that has? Is endorsement by leadership – either administrative or clinical – the most important factor?

I so look forward to seeing my colleagues from Brigham and Women’s; those clinical experts with superb teaching skills and admirable cultural competency to work with me to answer these questions, as we continue ventures in global nursing.