Life Lessons for Lexie: Africa Edition: National Nursing Examinations

I started writing this five days ago, but figured maybe I should finish it now that the week is over. I walked into a surprise last Monday morning... apparently, I had been selected to be an examiner for the national nursing examinations!!! I had no idea what this entailed, I think my directions had gotten lost in my Junk Mail so I was completely unprepared. I quickly figured out though that I would have to put all my work in the ICU on hold for two weeks.
Here in Rwanda the nursing candidates have both a written exam they must take and a practical skills exam. I have been grading the candidates for the past week on their practical skills. It's been quite the eye opening experience. For starters, I had some serious doubts about my ability to grade candidates when I don't understand Kinyarwanda and their French is not what I'm use to. But I quickly got use to it. There were four Rwandans and me and another HRH nurse, Steph. Steph works in pediatrics and ironically is my Baltimore pal. She grew up in Fallston and worked at University of Maryland Medical System. She's been a life saver here and I really hope that she extends her contract. She was a mid year hire for year 2 so as of right now she is headed back stateside in February. She is the youngest of us all but so full of wisdom it astounds me at times.
Anyway... she and I were the lucky chosen ones. The first day we were able to shadow a pair of Rwandans so that we understood the process and what was expected of us. Here is how the nurses practical goes... they are given a patient and are expected to interact with the staff to find the patient's file (chart). After a review of the file they are to suppose to assess the patient and come up with the priority of care and procedure they are to perform. The procedures ranged from medication administration, changing urinary catheters, wound dressing changes, blood draws, placing IVs, and blood administration. After they performed their procedure we were able to ask questions and have them verbally give us a nursing care plan, complete with nursing diagnoses, which they really love here.
The first few days were tiring, but went well. I was paired with a Rwandan, Martine who works at King Faisal hospital, the only accredited hospital in the country. It's also private. Anyway, Martine was hardcore. She threatened to finish a student's examination because he started to talk back and argue with her over technique. She and I were on the same page in almost every aspect and after three days of testing I had failed 60% of the students I'd seen. It was rough. The most difficult for me was the fact that the vast majority of the student's could not speak or read English. You might be saying, "But Alex/Lexie/Toast (whatever it is you call me) you're in their country, they shouldn't be expected to speak your language!" And I agree with you, although my Kinyarwandan is not really improving despite my attempts at learning. However, the issue is that the Rwandan government has made English the official language of the education system. But from what I've been told, the students are still able to take their licensing exam in French. Not that big of a deal, but the physicians and medical students almost exclusively write orders in English. It just blows my mind that the nurses aren't taught enough English to read the files. In fact, in one of my last cases because the student couldn't read, and didn't ask for adequate translation she wanted to give a medication that wasn't even ordered by the team and she didn't understand why she couldn't just do that.
I quickly learned that the way that some procedures are just so different than how we do things in the US. For example, my medical friends would be shocked that the students are taught to use saline when preparing to insert a foley catheter (in ICU and pediatrics they use iodine so we don't know why it's different in the wards) and clean from mid thigh, up towards the female patient's va-jay-jay and then down. So different. And I already knew this, but day, after day, watching the same thing over and over again was very draining. I was getting to work at 6:15ish with Vanessa so that I could do two hours of work before starting the examinations about 8:30 am or so. By 1:30 we would just be finishing the third student if we were lucky. Steph and I were at work until at least 7 pm, if not later every night last week (I satyed until 9:15 pm doing work in the ICU one night). It was just exhausting. The language and procedural steps were just the tip of the iceberg too. Questioning their knowledge base at times was painful.
"What classification of medication is amoxicillin?" "A steroid."
"Why are you giving this patient dexamethasone?" "For pain relief."
"What is this patient's medical diagnosis?" "Je ne sais pas."
"If this patient has a sick liver, why are you giving the patient vitamin K?" "I don't know." "Ok, tell me some functions of the liver." "It secretes insulin."
When a candidate was able to connect the dots I was thrilled and incredibly proud of them. The odd thing is that despite the horrendously wrong answers, some of these students still passed. It was so frustrating to me. The current weight system for grading the students is such that theory and knowledge were less than 20% of their grade combined. 18% of their grade was their behavior, 18% performing their procedure, 6% physical assessment and so on. I'm fairly certain of the 25-30 students I graded over the 7 days, only 2-3 of them used their stethoscopes to listen to the patient's lungs. I was lucky if the candidates did anything more than vital signs. I hope that the National Nursing Council starts to revise the grading system based on the new curriculum that is now being taught in the universities.
Then there were the staff nurses who just wanted to help the students. I'm pretty sure that I've mentioned that the idea of team nursing is very very strong here, to the point that making nursing assignments is a very novel idea. Some of the staff nurses told the students what procedure they were suppose to be doing. I sent a very frustrated SMS to Steph as it crept on to 6 pm one day:

Me: Sigh. The nurse just handed the student the blood and tubing to be transfused before the student even looked at the chart.
Steph: Oh man. I'm sorry. They know better.
(pause for ten minutes)
Me: It's all good. The student tried to give the blood to the wrong patient anyway.
Steph: At least it was O negative.
Me: Valid point.
(pause for another five minutes)
Steph: I just realized that I've totally forgotten alcohol swabs exist.
Me: Yep. When you watch nursing students wipe tops of vials with sterile gauze for four straight days you tend to forget these things.

We had seven days of the frustration building. But now that it's over, I'm glad I got to do it. It actually has helped me communicate with my staff better in an odd way. Just spending all that time with Rwandan colleagues and the nursing candidates taught me concepts that are important to them and where they come from. It's so drastically different than my nursing education that it's important to have reminders of the differences in my search for common ground.
Halloween was last weekend and it also happened to be Steph's 26th birthday. I'm impressed she and I were able to have so much fun last Friday night we were so exhausted from the exams. My roommates and I hosted the party and it was great fun. There were snacks, cake, music, costumes, and of course alcohol. We had a good time just hanging out at the house and then someone brought up dancing... so most of us went out at 11 pm to go dancing. And boy did we dance. The Rwandan university students loved us. I made the mistake of asking one of them how old he was... 18. I almost died. But it was such a great time and it was much needed. I didn't get in bed until just after 3 am (and the club we were at has DJs until 6 am mind you) and really slept in last Saturday. Below are some photos. More later!

Lesson Learned:
1) The system here isn't going to live up to my expectations or wants, but there is the hope that things will slowly improve over time.