Empowering Nurses to Improve Care in Haiti

A circle of nurses pauses at one bed and then the next, discussing the progress of each patient inside a clean, spacious ward of University Hospital in Mirebalais, Haiti.

They approach the bed of a woman with end-stage AIDS. She is emaciated, awake but hardly responsive. Looking at her file, the nurses see she’s not taking her medicines or eating. The doctor suspects depression and has ordered an evaluation from the hospital’s mental health specialists.

The nurses take a closer look. One gently says, “cheri, can you take a drink for me?” They watch her, and then ask why she hasn’t been taking her medicines. The reason: she’s having trouble swallowing, and is afraid she’ll choke on the pills she’s been prescribed. With this insight, they arrange for her medicines to be given through an IV drip and her food to be liquid, greatly improving her care.

This sort of “aha” moment is what Partners In Health nurse leaders want to happen many times a day in PIH-supported hospitals and clinics. Research from the United States and Europe shows that good nursing care improves patients’ health—no surprise to those who understand nurses as the care providers in most intimate contact with patients. So PIH and our Haitian sister organization, Zanmi Lasante, are this month opening a Nursing Center of Excellence at University Hospital—a hub for nurse mentorship, leadership, and specialization to raise the standard of nursing in Haiti.

“I want our nurses to think critically, to go beyond the task of doling out medicine,” said Marc Julmisse, chief nursing officer at University Hospital, who led nursing rounds on the day the nurses intervened for the woman suffering from AIDS. “By thinking holistically about the patient, nurses can make a huge difference.”

Haiti has a long way to go before this vision is reality. The country has many nursing schools, but of those, only a handful are public, and only 32 are recognized by the Haitian Ministry of Health. The country is just beginning to implement a standardized curriculum and to introduce specialties to help nurses advance in providing complex care. Nurses in Haiti are rarely trained as specialists, making it difficult to deliver complex services such as cancer care and intensive care.

All this was the case even before the country’s 2010 earthquake destroyed the public nursing school in Port-au-Prince, killing an entire class of students and many faculty.

The Nursing Center of Excellence offers standardized, specialized training programs, mentorship, and supervision based on a successful PIH pilot in Rwanda, and opportunities for nurses to become educators. So far, PIH/ZL has promoted eight nurses from within the system to serve in leadership roles as educators or mentors. PIH/ZL nursing leaders have also appointed nurses to serve as disease-specific specialists in each PIH-supported facility—connecting efforts to fight malnutrition and HIV and tuberculosis, for example, and serving as advocates for quality care in the institution and in the community.

With all these efforts, PIH/ZL nurse leaders hope to build on nurses’ roles as patient advocates, both on the level of the health system and in the treatment of individual patients.

“Raising the status of nurses is part of the PIH approach of empowering the people closest to the problem,” said Sheila Davis, chief nursing officer at PIH. “It is the nurses by far who are closest to patients, who can see what needs to happen to improve their care.”

Nursing rounds are a new approach in Haiti that PIH/ZL nurse leaders designed to challenge nurses to think critically about patients and how they can help meet their needs. Julmisse and the hospital’s nurse administrator, Naomi Marcelin, go into rounds prepared to test the knowledge of the nurses on the floor about each patient’s diagnosis, treatment plan, and risks—including side effects and hazards such as falls or bedsores. Julmisse wants the nurses to think about all the ways they as nurses can help the patient—including advocating for changes to their care when necessary.

For example, a man with a broken neck has to lay on his back without moving his head. When the nurses visit the patient during rounds, Julmisse asks what the implications of this might be. If he has to lay on his back, he might have trouble swallowing. He may become dehydrated because he can’t drink. Nurses can help by making sure he always has a straw or by providing IV fluids. They should also think about his mental health. All these responses are rooted in medical science, and require critical thinking about the patient’s condition to prioritize needs and interventions.

“On nursing rounds, our staff starts thinking about what they can do for this patient rather than just focusing on the task of giving a pill,” Julmisse said. “These are things that nurses can do that require them to advocate for the patient.”

The Nursing Center of Excellence has a space in University Hospital in Mirebalais, but it represents efforts to improve nursing care across the 12 facilities PIH/ZL supports in central Haiti. Nurse mentors and educators are located at five community clinics and hospitals around central Haiti, and nurses from across the PIH/ZL network attend trainings at University Hospital.

While the mentor and educator teams are small, they provide essential training to hundreds of nurses and nurse assistants. Their role is to train in two ways—first, through formal education, and second, through on-the-job coaching.

From neonatal resuscitation to infectious disease management, educators teach lifesaving skills and concepts based on the latest clinical science and suited for the setting. And mentors reinforce those skills in clinics and hospitals—the key function of translating book learning into practice.

Some of the improvements to the nursing system are simple, yet powerful. For example, the nursing team now has its own vehicle, which is critical for the nurse leaders to be able to visit various health facilities, see how nurses are doing, and help solve problems. It also makes a statement about nursing, because vehicles signal importance in a place where few people have personal cars. Another simple improvement is that PIH/ZL Chief Nursing Officer Beatrice Romela advocated for a nursing office in the PIH/ZL office in Port-au-Prince. Before, she worked at a drop-in desk.

These investments add up, signaling that nursing leaders are essential to good health care and not peripheral actors in health care delivery.

“My vision is for ZL nursing to be a model for all nursing in the country, with excellence in education and patient care,” Romela said.

And the investment in nurses is already showing results. During one site visit in Verrettes, a community clinic supported by PIH/ZL, Romela met a Ministry of Health nurse who was working in the malnutrition program without a regular supply of therapeutic ready-to-eat food, Nourimanba, which PIH/ZL produces from Haitian peanuts to treat malnourished children. Nor did she have an experienced leader to help her learn the proper assessment and follow-up skills to ensure quality care.

“People stop asking for things because they think they’re never going to get it,” said Sheila Davis, PIH’s chief nursing officer. “We’re building more of a system so people feel they’re not out on their own.”

Romela connected the Ministry of Health nurse to the PIH/ZL appointed nurse leader on malnutrition across central Haiti, Marie Landy Zamor, who could support her in the future with medical and programmatic advice, training, and supplies.

When Romela returned in April, the program had improved substantially, as evidenced by data showing that more children were receiving adequate follow-up at the clinic and through community health worker visits. The nurse proudly opened the once-bare cabinet to reveal jar after jar of Nourimanba.