Training Nurse Leaders in Intensive Care

The baby boy arrived 14 weeks early and weighed less than 2 pounds. Nurse Thamar Julmiste received him from labor and delivery staff at St. Thérèse Hospital in Hinche, Haiti, and immediately noticed he wasn’t breathing. She and Nurse Nathalie Casimir luckily knew what to do. They performed CPR on the impossibly tiny newborn and were relieved to see his birdlike ribcage rise and fall on its own.

“People didn’t think he was going to live,” Julmiste recalled.

But he did. Julmiste followed what she and seven of her colleagues had learned during a training for nurses on neonatal intensive care organized by Zanmi Lasante, as Partners In Health is known in Haiti. Now, a new cohort of 26 nurses from around the country are following in her footsteps by studying neonatal and pediatric intensive care. The free, 24-week-long training at University Hospital in Mirebalais, which PIH supports, will provide them with a foundation in theory and clinical skills in both neonatal and pediatric intensive care.

Graduates will receive certification in July from the Haitian government and—if PIH’s efforts prevail— be the first among a growing group of neonatal and pediatric intensive care nurse specialists in Haiti.

“Everyone deserves the best level of care,” says University Hospital’s Marc Julmisse, the chief nursing officer who is spearheading the training. That’s only possible when clinicians receive the best training available, so she’s helping prepare this group of nurses to think critically and develop the specialized skills necessary not just to follow orders, but to “become a valuable member of the patient care team.”

A typical nurse’s training in Haiti includes four years of university education. After that, opportunities exist to specialize in midwifery or community health. If they want other types of advanced training, they must travel outside the country, and most stay to work there afterwards. It’s all part of the brain drain that has afflicted Haiti for decades, as the country’s brightest minds leave in search of higher education and better job opportunities. PIH clinicians in Haiti are definitely an exception, considering they have chosen to stay and practice medicine in their home country while training the next generation.

Our expectation is that you’re going to be a leader.

An expert neonatal nurse herself, Julmisse understands this reality and is part of a team working to build in-country specialized training for PIH nurses and, for that matter, all nurses throughout Haiti. She launched a pilot program in neonatal intensive care last year from which 25 nurses graduated. Lessons learned from that pilot informed the current neonatal and pediatric intensive care training in Mirebalais.

The Haitian Ministry of Public Health and Population chose from which hospitals to recruit trainees. Then Julmisse and her team sent out invitations to 11 locations (many of them PIH sites), including: Gonaïves, Jacmel, Jérémie, Saint-Marc, Petite-Rivière, Hinche, Mirebalais, Belladère, Cange, Diquini, Jean Denis. Interested nurses filled out an application and wrote a personal statement about why they wanted to be chosen. To qualify, they had to be licensed, have worked at least one year in pediatrics, and have dealt with critical cases at their hospitals.

In late January, 26 nurses began their training in University Hospital, where they have one day of lecture followed by a day of clinical practice in the wards. They return home the rest of the week to their regular jobs and apply what they have learned.

Julmisse recruited PIH clinicians to help teach, such as Dr. Christophe Milien, the hospital’s director of obstetrics and gynecology, and Meredith Jean-Baptiste, the hospital’s maternal health coordinator. She pulled from contacts she has made over the years at Ohio State University and Boston Children’s Hospital. Together they designed the curriculum and have taken turns lecturing and mentoring the nurses. Last year’s graduates based at University Hospital, such as Nurse Lauria Cadet and Nurse Manager Alexandra Millien, also co-facilitate and serve as translators for English-speaking instructors who aren’t well-versed in Krèyol. And PIH’s Boston clinical team helped manage logistics from afar.

Nurse Lauria Cadet (left) observes Nurse Joseberth Joseph as she draws blood from a newborn inside the Neonatal Intensive Care Unit at University Hospital in Mirebalais, Haiti.

Nurses study increasingly complex information and techniques as the weeks pass. In neonatal care, for example, they first learn how to properly assess a mother’s prenatal history to anticipate complications during labor and delivery, and they monitor a baby’s vital signs as the newborn transitions to life outside the womb. Deeper into the training, they learn symptoms of cardiac anomalies and respiratory distress in newborns and how to treat them.

Instructors assess the nurses based on their knowledge, skills, and attitude. It’s a pass-fail system. And that’s as it should be, considering lives literally hang in the balance based on the nurses' ability to perform under pressure.

Julmisse sets a high bar for nurses from their first day. “You’re not in the training because you had nothing better to do,” she tells them. “If you can’t keep up to expectations, then this is your time to leave.”

So far, no one has looked for the exit. Possibly that’s because they feel just as strongly Julmisse does when she asks: “Are we here to prolong a death, or are we here to save a life?”

Still, Julmisse knows that 24 weeks is not enough time to turn these nurses into experts in neonatal or pediatric intensive care. She does believe that if they put in the time and work, they will leave competent to handle complex situations and serve as examples for junior staff.

“Our expectation,” she tells them, “is that you’re going to be a leader.”

Their July graduation isn’t the end of these nurses’ professional development. Julmisse says her team will follow up with each graduate for a post-training evaluation after one month, six months, and one year to see if, as she says, “the concept has been transmitted.” She heavily encourages them to become members of Haiti’s National Nursing Association and soon-to-come Critical Care Nursing Association. She is even encouraging them to attend the first neonatal conference to be held in Haiti around this time next year.

Back in Hinche, Julmiste and her colleagues who took last year’s training know they are doing good work. She thinks of the premature baby whose life she helped save and understands the importance of continuing education.

“Nurses should take this training,” she says, “because with more nurses knowing [how to handle these situations], we will save more children.”