Translating Clinical Education to Nursing Practice in Rwanda: Enhancing Maternal and Child Health

Nursing is a dynamic profession for which nurses need to continuously update their knowledge and skills (Adeniran, Smith-Glasgow & Bhattacharya, 2013).  As members of the healthcare team, nurses need continuing education to keep up with changes in the healthcare environment.  Evidence shows that approximately 25% to 35% of acquired knowledge is forgotten one year after its acquisition (Custers, 2010).  As nurses constitute the backbone of the healthcare system, the need to maintain and update their knowledge and skills is paramount to achieving improved patient outcomes.  One of the areas which is important to update is newborn resuscitation.  It is important for nurses to have the knowledge and skills about the current practices pertaining to newborn resuscitation.  

According to the World Health Organization (WHO), each year, three million deaths occur during the neonatal period worldwide (2013).  Approximately 99% of neonatal deaths occur in developing countries with the highest rates in Sub-Saharan Africa (Lawn, Cousens & Zupan, 2005).  Despite a global decline in the mortality rates among children aged five years and under, neonatal mortality is either increasing or not changing in developing countries over time (United Nations International Children’s Emergency Fund [UNICEF], 2013).  Unlike developed countries where neonatal mortality rates are low, developing countries show excessive neonatal mortality rates (Lawn et al., 2005).  For example, the neonatal mortality rate per 1000 live births is estimated around 43 in Burundi and 21 in Rwanda compared to Denmark and Canada where the neonatal mortality rates are approximately 2 and 4 per 1000 live births respectively (United Nations, 2011). 

Lawn et al. (2005) highlight that about 23% of the neonatal deaths in developing countries are related to birth asphyxia.  In Rwanda, neonatal asphyxia is the leading cause of mortality accounting for 38% of all neonatal deaths (Republic of Rwanda, Ministry of Health, 2012).  It is documented that inadequate knowledge and skills for newborn resuscitation among birth attendants contributes to increased neonatal deaths in developing countries (Hoban et al., 2013; WHO, 2013).  In an effort to reduce neonatal mortality in resource limited areas, the American Academy of Pediatrics (AAP) instituted the Helping Babies Breathe (HBB) course in 2010 (AAP, 2010).  HBB is a hands-on short continuous professional development (CPD) course which is delivered through the-train-the trainer model.  In this model, experts in newborn resuscitation train local birth attendants through theoretical knowledge and resuscitation skills (AAP, 2010).  Afterwards, the local trainers train their fellow birth attendants in newborn resuscitation (Korioth & Writer, 2010).

Studies demonstrate a positive relationship between the reduction of neonatal mortality and in-service neonatal resuscitation education for nurses and midwives in developing countries (Carlo et al., 2010; El Fattah & El Dein, 2012).  Lee et al. (2011) found that neonatal resuscitation education for practicing birth attendants reduce intrapartum-related mortality by 30%.  Likewise, Carlo et al. (2010) found that the neonatal mortality rate during the first week following births in Zambia decreased after two neonatal resuscitation educational programs were carried out for birth attendants.  Similarly, results from a study conducted in Rwanda (Musafili, Essen, Baribwira, Rukundo & Persson, 2012) and another from Ethiopia (Hoban et al., 2013) indicated increased knowledge and skills in newborn resuscitation among nurses who attended HBB educational sessions.  However, nurses face many challenges in applying the knowledge and skills gained through in-service neonatal resuscitation courses (Bream, Gennaro, Kafulafula, Mbweza & Hehir, 2005).  The majority of existing body of literature to investigate the effectiveness of newborn resuscitation courses in reducing neonatal mortality in developing countries uses the post positivism paradigm and quantitative methods (Carlo et al., 2010; El Fattah & El Dein, 2012; Little, Keenan, Niermeyer, Singhal & Lawn, 2011; Musafili et al., 2012). 

Despite the evidenced role of newborn resuscitation in reducing neonatal mortality in developing countries, birth attendants continue to face barriers to the application of the knowledge and skills they gain through neonatal resuscitation education.  Only one study using qualitative approach to study factors that hinder or facilitate nurses from proper newborn resuscitation was retrieved.  This study was done by Bream, Gennaro, Kafulafula, Mbweza and Hehir in 2005.  Bream et al. (2005) conducted their study in one central hospital in Malawi.  Nurse-midwives who participated in this study reported that their rich experience and commitment to their job were facilitators to performing newborn resuscitation.  However, they also voiced several barriers that prevented them from performing newborn resuscitation.  Participants reported that they often missed basic equipment for newborn resuscitation such as the linen to cover up the baby, warmer table, and the clock to estimate the APGAR.  Understaffing was also considered by nurse-midwives as a barrier to timely newborn resuscitation.  For example, nurse-midwives participating in the study reported having to leave the suffering baby unattended to care for the dying mother, which in some cases resulted in the death of the baby.  Inadequate communication between the nursing, administrative, and equipment maintenance staff was reported by participants as a negative factor to newborn resuscitation.   Above the mentioned factors, lack of posted newborn resuscitation protocols in delivering rooms constituted a big challenge to nurse-midwives to perform proper newborn resuscitation in Malawi.

The literature review highlights that ‘in-service’ newborn resuscitation courses increase knowledge and skills among nurses.  Nonetheless, we still need to know about nurses' experiences of translating new knowledge and skills into practice after participating in clinically-based continuing education such as newborn resuscitation courses.  In addition, factors that hinder or facilitate nurses in developing countries to apply the knowledge and skills they gained from participating in such courses in their professional practice need to be explored. 

Therefore, the purpose of this research was to use a qualitative descriptive study design to explore nurses’ experiences of translating knowledge acquired from education workshops focused on maternal, newborn, and child health (MNCH) into practice in Rwanda.  After receiving ethics approval in Rwanda, nurses in the Eastern province of Rwanda were invited to participate in the Helping Babies Breath (HBB) educational workshop. Prior to the start of the workshop, nurses were provided with a letter of information about the study and a consent form. Nurses who wished to participate in individual interviews at least 4 weeks after the workshop signed and returned the consent form to a research team member. Thus, a purposeful sampling strategy was used to select 10 nurses to participate in audio-recorded individual interviews to gain an understanding of how nurses described applying the knowledge they developed from the HBB course into practice.  After the audio-recorded interviews were transcribed verbatim, content analysis of the transcripts was conducted to identify emergent categories and themes.  The initial thematic findings, related to knowledge and skills gained from the education workshop and facilitators and barriers to applying knowledge in practice, will be presented at the convention.  In particular, findings suggest that nurses’ professional development would greatly benefit from additional maternal, newborn, and child health-focused educational workshops. It is proposed that, in turn, increased professional development through continuing education would lead to a higher quality of nursing care and improved patient outcomes. Further, Rwandan healthcare delivery could be improved and newborn mortality reduced if newborn resuscitation continuous professional development courses were established on an ongoing basis. Overall, the health care delivery in Rwanda could be strengthened by the service of more knowledgeable nurses. These findings could inform continuing professional development offerings and health human resources policies and planning to address nurses' continuing education needs in Rwanda.