Increasing Nursing Student Interest in Rural Healthcare: Lessons From a Rural Rotation Program in Democratic Republic of the Congo
Authors: Michaels-Strasser Susan , Thurman Paul W. , Kasongo Narcisse Mwinkeu , Kapenda Daniel , Ngulefac John , Lukeni Beatrice , Matumaini Serge , Parmley Lauren , Hughes Rebekah , Malele Faustin 
Published: December 2020

Abstract
BackgroundMany challenges exist in providing equitable access to healthcare in the Democratic Republic of the Congo (DRC) including resource disparities between rural and urban areas coupled with a majority rural population. One of the most promising ways to close the gap between rural and urban healthcare access and quality is through the support of human resources for health (HRH), especially nurses, in rural health settings. Current barriers including lack of nursing students from rural communities, insufficient infrastructure, and absence of programs for rural practice exposure, have allowed disparities between rural and urban healthcare to persist. MethodsTo implement a rural rotation (RR) program for nursing students in DRC, whereby students are immersed in a rural clinical and community placement for an extended period of time, ICAP at Columbia University (ICAP), with funding and support from the United States Health Resources Service Administration (HRSA), consulted with stakeholders in DRC including students, the Ministry of Health (MoH), the Ministry of Education (MoE), and nursing schools and associations to improve health workforce education including understanding the disparities and realities of rural health care. Following this, schools of nursing in the Lubumbashi area agreed to add nursing students into rural workforce settings, including time in clinical as well as community health on a rotational basis. ICAP then worked with the MoH and MoE to select rural sites that could adequately support rotating nursing students and develop expectations for the RR program. Assessments of the selected rural sites were conducted, and the availability of nursing mentors, teaching materials, security, and accessibility, as well as patient volumes, were identified. Building on prior work to strengthen preceptors, a training of trainers approach was used. Out of a cohort of 85 trained preceptors from across 55 target schools and 30 rural health facilities, 30 were selected to be “master trainers” based on their experience in training others, their performance in initial preceptor training, and willingness to contribute more to overall success of the RR program. These master trainers educated the remaining 55 preceptors in rural practice. Concurrent with the training, ICAP, along with the MoH and MoE, worked with communities around the rural health facilities to secure accommodations for nursing students and to engage them with community leaders for purposes of future health promotion and clinic collaboration.ResultsAll five target schools from the Lubumbashi area that were selected for the project chose to participate. Kinshasa was not targeted for the project but did have two schools in rural areas outside the urban center interested and willing to accept students on rotations. Over the life of the project, 583 students successfully participated in the program and completed rural rotations as planned. Sixteen rural sites and 298 students participated in the rotational program during the 2018-2019 school year. For the 2019-2020 school year (through March), 285 students participated.Post-rotation feedback RECEIVED FROM 274 students, as well as from over 25 preceptors, and nursing school leaders, has been very positive and has resulted in more nursing students seeking rural assignments upon completion of their studies. Ninety-three percent of students surveyed, for example, indicated that they agreed or strongly agreed that they would recommend participation in RR programs to their classmates. Ninety-seven percent agreed or strongly agreed that their RR program had strengthened their education experience and increased their willingness to serve in rural areas in the future. The most significant challenges, however, were financial support (35%) and housing (30%).ConclusionsWith nearly 600 successful participants, this project showed that a RR program is both feasible and acceptable for nursing students, faculty, and rural clinic staff in resource-limited settings. Student exposure to rural practice is critical to increasing interest (and therefore downstream HRH staffing) in rural area healthcare. ICAP, HRSA, and DRC ministry leadership believe these early successes are indicative of both the opportunity available and value-added of such a RR program. Going forward, HRSA, ICAP and key stakeholders will continue to collaborate to sustain this project and advocate for employment and placement of student nurses who expressed interest, into rural employment following graduation. In addition, expanding such programs to other majority rural areas of sub-Saharan Africa seems both feasible and affordable with the right up-front collaborations and program design with key stakeholders.