Professional Development
Design.
Employer
Location
Timeline
My role
Team
Human Resources for Health Program
Butare, Rwanda
12 months
Project & Design Lead
lCU Nurse Lead
Between 2012 -2018, the Rwandan Ministry of Health partnered with a consortium of 23 US academic institutions to increase the capacity of its healthcare education system. The Human Resources for Health Program's primary objectives were to grow the number of skilled professionals and educators, and to improve the system's infrastructure.
As a critical care nursing instructor in the program, I spent one year designing and piloting a training course for 21 nurses who worked in one of the country's four intensive care units (ICUs). The first of its kind and Rwanda, it was based on existing courses, adapted for context constraints, endorsed by the University of Rwanda upon its completion, and accepted to the International Forum on Quality and Safety in Healthcare that was held in London the following year.
The challange:
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Lagging training: The speed of technological advancement had exceeded that of continued professional development, resulting in varying and sometimes outdated patient care practices.
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Career limitations: Because professional certifications did not yet exist, nurses lacked a career ladder and therefore had little incentive to invest time time in continued training.
IV Fluids
Cardiac monitor
Ventilator
Blanket warmer
Humidifier
ICU Bed
ICU equipment had advanced rapidly, making it difficult to maintain up-to-date training.
Context + constraints:
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One year timeframe, open format: I was contracted for 12 months, full time in the ICU, with little expectations on instructional format or content.
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Local expertise: The program developed a structure of "twinning", wherein I was paired with a highly motivated nurse for the duration of the year, to collaboratively create improvements.
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Post-colonial context: Resource limitations existed that were typical of a post-colonial, globally exploited context.
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Staffing shortages: Per one of the reasons the program was created, there were longstanding national staffing shortages.
Project goals:
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Increase the knowledge and skills of the ICU nurses
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Improve patient care quality
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Expand professional opportunities
Process steps:​
Participate and connect: While I was accustomed to teaching critical care nursing, I was totally unfamiliar healthcare in Rwanda. Additionally, I occupied a role that, when performed poorly, could manifest with problematic neocolonial overtones of expat 'expertise'. Above all, I needed to (and wanted to) genuinely connect with the ICU staff before starting to 'teach' at all. Arguably, I had more to learn than teach.
Assess needs: While it was important and straightforward to identify topics that might fulfil the project's goals, it was critical that I understand what the staff desired, their pain points, and unmet needs. Finally, it was crucial to collaboratively define what was realistically feasible given time and space constraints.
Methodologies:
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Participant observation
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Unstructured interviews
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Repeated surveys
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Staff meetings
A survey helped determine topics of interest and logistical need for a viable plan. Survey results the provided prompts for both planned and informal conversations
No guarantee of career advancement: Nurses would need to devote many hours each week to training, but the undertaking might not yield tangible value.
Challenge
National endorsement: We were able to secure endorsement from the University of Rwanda.
Solutions
Minimized time commitment: With support from the ICU medical director, we were able to hold the course in an extra room in the ICU, enabling nurses to attend it during their work hours.
Unified participation: Official backing from a high level institution provided incentivizing explicit value, and immediately accessible classes resulted in every ICU nurse deciding to take the course.
Impact
Finalize scope and plan: xxx
Locate resources: Because courses already existed for critical care nursing certification, it was far more efficient and effective to model a course from an existing curricula. Additionally, subject matter expats from both Rwanda and abroad were available to help determine adaptations to best practices.
Physicians were readily available to help
Create content: We collaboratively scoped the project and planned that I would design and teach 16 two-hour modules over the course of seven months. The major lift was creating slide decks for each module, that were the basis of the classroom instrution and that were designed to be a resource for future reference.
Critique & learnings
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Unexpected challenges: xxx
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With more resources we could have: xxxR
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Retrospective concerns:
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Sustainanble??? (This plan also meant that I would need to teach each course 3 times to meet scheduling needs, and that classes would need to pause when a patient needed care. We made it work!)
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xxx​
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Final take-home:
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A collaborative, inquiry-Âbased approach to capacity building facilitates the identification of real needs, and creation of viable solutions.
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Unexpected win: Drastic improvement in one aspect (training) of a system (healthcare) produces both a demand & opportunity for parallel improvements, such that system growth is cohesive & can support sustained change: immediate need (& opportunity) to renovate medical record.
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Next steps: Given successes with this pilot project, the HRH Program is working to scale nursing specialization training to a national level. Both opportunities & questions abound regarding participants, trainers, certifying bodies, & continuing professional development recognition.
Create evaluation tools / M&E: To measure the efficacy of the project, I needed to create tools (exams) to establish baseline knowledge and measure improvements through the course.
Teach for seven months: Given scheduling limitations, in order for all nurses to attend the required 90% of the sessions, I taught each three times.
Final solution:​
Ultimately, we successfully pulled off Critical Care Certification Course that spanned seven months, comprising 16 modules that were each approximately two hours long, and that I taught three times for scheduling accessibility.
Instructional methodologies & tools:
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Didactic classroom instruction
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On-the-job clinical training
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Case study group exercises
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Detailed slide decks
Learning assessments:
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Preliminary comprehensive exam to establish baseline knowledge
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Pretest and posttest assessments for each module
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Midterm exam
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Final written and clinical exams
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Knowledge retention exam six months after course
Classes took place in an unused ICU room
Written and clinical exams were required for certification
Impact:
Wins, losses, learnings:
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Surprising win: xxxy
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Unexpected hurdle: xxx
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With more ______ we would have... xxx. ​
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Most valuable learning: xx
Quantitative
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47% improvement: Final exam scores showed a 47% increase in knowledge about critical care nursing (median test scores).
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81% knowledge retention: Retention exam given six months after the course finished showed the nurses had retained 81%.
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Daily application: Also at six months, 95% of nurses reported that they they applied what they learned daily.
Qualitative
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Consistent practice improvement: Both ICU nurses and physicians shared that the department had implemented daily evidenced-based practices, including ventilator-acquired pneumonia prevention and scheduled patient turning.
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Boost in morale: The project was accepted to an international healthcare quality improvement conference in London, providing a boost in moral and sense of accomplishment. Many of the nurses said that the course "inspired them to be a better nurse".
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National training development: Based on its success, the Ministry of Health planned additional courses for other nursing specialties.
Our submission to the
International Forum on Quality & Safety in Healthcare in London.
