Ruanda: Wir müssen die Pflegeausbildung ausweiten

We need to scale up nursing education, not scale it down

Rwanda's ministry of education has reintroduced nursing at upper secondary or A-Level and a few days ago invited applications for those wishing to study nursing at this level in a few selected schools. The decision is a noble idea, especially considering the domestic and indeed regional and global demand for community health workers and nurses in light of the available number of doctors and population increase.

A strong, properly trained and skilled workforce of health workers, among them nurses and midwives, is the backbone of a well-functioning health system in any country. But their education and training, recruitment, deployment and retention remain major challenges for many countries, including Rwanda. And so any measure to meet these challenges is welcome.

However, the introduction of nursing as a subject in a science combination in general education must have been an oversight pedagogically. Nursing is a professional course with many subjects and ought to be a stand-alone training like any other medical related courses or professional or vocational course. It is not really necessary to lump it together with other subjects and demand that trainees excel in these as well. It only overloads them with content for which a foundation for their level of training has been laid at the level of basic secondary education.

The new nursing assistants course has 17 subjects, out of which ten are general education subjects whose instruction time is 39 periods out of a total of 60 periods per week. That leaves only 21 periods for the core nursing subjects. Clearly not enough time for the acquisition of the relevant knowledge and development of professional skills.

An analysis of time allocation for the general subjects alone shows how skewed this is. For example, Chemistry has 7 periods, Biology 7, Physics 6, Math 3, English 4 and entrepreneurship 2. This allocation and content is similar to the physics, chemistry, biology (PCB) combination in most Commonwealth countries, including Rwanda.

This is quite a heavy load, skewed to the purely academic, especially considering that professional and vocational education in this century is supposed to be focused on hands on skills development accompanied by relevant and linked subjects. In any case, the new course is meant to train nursing assistants and so a disproportionate amount of academic content is not likely to be very helpful.

According to World Health Organisation (WHO) recommendations adopted at the 62nd session of the regional committee for African health ministers in 2012, nursing as a course is supposed to have the following subjects: foundation of nursing practice, pathology, pharmacology, health observation and assessment, anatomy and physiology, clinical and laboratory skills, parasitology, biochemistry, microbiology, human development, medical ethics, drug classifications, and use and health care, including adult and child care.

The coverage of these subjects is consistent with the "roadmap for building the human resources for improved health service delivery in the Africa Region 2012-2025".

The nursing profession and the requisite training in Rwanda have evolved over the last twenty-five years, the point of departure being the establishment of the Kigali Health Institute (KHI) to train nurses at higher diploma level. This was followed by the setting up of five regional nursing colleges in 2007 that trained nurses at AI level (Assistant de premier class). The goal was to reinforce KHI and train more middle level nursing professionals at a tertiary level to work in hospitals, dispensaries and health centres, and eventually to serve the community and to fill the gaps in the local labour market and even beyond our borders.

Before then few nursing schools offered traditional professional subjects mixed with a good number of general subjects without the appropriate linkages. The training concentrated on teaching general subjects and did not equip our basic level technicians and health workers with the skills necessary for a modern healthcare system and for the domestic and external labour market.

The establishment of the colleges was followed by the phasing out of A3 (Assistant de troisieme class) and A2 (Assistant de deuxieme class) programmes that were offered in nursing schools where the training was treated as a course and not as a subject.

This phasing out of the lower level nursing courses was in keeping with recommendations of a study commissioned by the East African Community in 2013. The study: Developing Regional Guidelines for the Harmonisation of Nursing and Midwifery Education for Recognition in EAC Partner States presented in January 2014, made several important recommendations.

It recommended the phasing out of certificate programmes (such as A2 and A3) by 2020 and the scaling up of nursing education where direct admission into the diploma programme should be completion of secondary education. This is already happening in most EAC countries where nursing education starts at the post-secondary level.

At the time Rwanda undertook to have all cadres of nurses and midwives in the country at all levels to be harmonised with the rest of the EAC countries.

It might appear like we are reversing the progress that had been made. For some yet unexplained reason, these five nursing colleges are not in operation, either suspended or closed. We seem to be going back on our committing to harmonisation of training in the EAC.

The country has also moved ahead. There are advances in every field, including healthcare. Expectations are higher. We should not return to the past but rather look to set up systems for the future.

And so today, the education of health workers in Rwanda should be looked at from the point of view of where the country has come from since 1994, where it is today and where it intends to be in at least 50 years to come. Those responsible for education policy, curriculum development and implementation should never lose sight of this. They must keep abreast of developments in the sector especially in professional and vocational training.

Training trends and practice in other parts of the world should also offer direction. In many countries today, the trend is towards university level training of nurses. It is becoming increasingly common for university graduates to enrol in a one-year post-graduate diploma nursing training course. A-Level leavers take a one-year diploma course in auxiliary nursing, while those who have completed only O-Level take a health assistants certificate course.

In most third world countries students enrol for nursing training after completing A level or upper secondary education without any other strings attached as long as they have an O level certificate or equivalent showing they studied biology and chemistry.

It is, of course, important to design a training programme suited to Rwanda's circumstances. That can still be done without incurring extra costs in terms of new infrastructure, training resources and creating an unnecessary burden on the entire system.

For example, the nursing colleges can enrol A-Level science leavers who already have the basic academic background that the new training regime requires. Or they can register those who have not joined university or wish to take short professional courses but meet minimum requirements for auxiliary or assistant health worker training. They could then be awarded an A2 diploma or any other name we choose to give it.

There are many school leavers who could jump at the opportunity for such training. But even if this was not the case, they can be mobilised to take the courses. By training these this country may narrow the number of nurses and midwives per 1000 population. In Rwanda the number is one nurse to 1000 people, while in the more advanced countries like Switzerland it is 18 per 1000.

Education programmes should aim to narrow this gap as well as raise the level of education of health workers. For this they must be taught by qualified doctors or graduate nurses and have access to clinical and laboratory facilities and patients.

• By Joseph Murekeraho; The views expressed in this article are of the writer.