I am a Social Scientist, a Health Systems researcher with the Kemri-Wellcome Trust Research
Programme.
My role in the Health Service that Deliver for Newborns has been co-leading qualitative
research aspects of the project for the last three years.
Nurses are very important in the delivery of care for newborns, so our work was looking
at the nursing culture in these hospitals, looking at what the barriers and enablers
are, for actually being a nurse in a newborn unit, and what that means in terms of service
delivery.
The methods that we used was initially inviting stakeholders and engaging them in understating
what the nursing issues are in the country, so these were mainly drawn from training institutions,
from the Ministry of Health and from the Nursing Council, and we are also doing ethnographic
work with front line nurses to understand what the culture of nursing is in those public
hospitals.
The advantages of social science methods is that they provide a deep understanding of
the phenomenon of interest - in our case, they provide a deep understanding of what
it means to be a neonatal nurse; it provides a deep understanding of what the social context
within which newborn nursing takes place.
Particularly useful for this project is that it enabled us to understand what are some
of the intangible things that you need to consider when you are coming up with a strategy
to try and improve how care is provided, particularly, in our case, task shifting strategy.
The main methods that we used in this work were ethnographic methods, so we were embedded
within these hospitals over an eighteen-month period, and we were using long form interviews
with the nurses - these are typically different from your usual question and answer ones,
we were looking for narratives and stories for the nurses about what it means to work
in those units.
We spent a lot of time doing non-participant observations, more than 250 hours observing
night shifts, weekend shifts and day shifts, and because we were there for such a long
time, we developed really close relationships with the nurses; we were able to talk with
them informally and keep diaries of this, so these were really innovative ways of to
understand what it means to be a nurse in the newborn units.
The newborn units themselves are small, very congested spaces, they will have anything
from 40 to 80 babies, but what is more surprising is that the ratio of nurses to babies, so
you will have one nurse to anything from 15 to 20 very sick babies, which makes it quite
a challenge for a nurse to work there, and most of the time the nurses are actually unsupported
to be able to provide that work - the mortality ratios were quite high – anything from 50%
going upwards and therefore it means that there were quite emotional spaces both for
the researchers and for the nurses themselves.
This interview was recorded in December 2018
Some of the key findings that we saw, unsurprisingly, the nurses were completely overwhelmed; they
had a very difficult job to do but also interestingly, they came up with different ways of coping.
I can think of three main ways they came up with that really stood out from this work:
One of those things was a way of prioritising tasks - they had developed a hierarchy of
doing those tasks, the more technical tasks were given more priority: making sure the
babies get their medicines, making sure they get fluids.
This was prioritised over the bedside care, which includes things like counselling mothers
or talking to a mother after they have lost her child, which was not given as much priority.
Another thing that came from our work was that there was already informal task shifting
happening in these wards: because the nurses are so stretched in terms of what to do they
were informally delegating to mothers, to students and to support staff, so some of
the things they were delegating are feeding the babies and cleaning the babies, and in
some hospitals, mothers were tasked with weighing and keeping feeding charts in the various
hospitals that we went to.
Lastly, the routines that nurses came up with included coming up with a sort of mental alert,
making sure they get through some tasks, so that at the end of the day they can say, “I
was able to achieve this”, so in each typical shift, they would make sure for example that
medicines had been given, fluids have been given, ward rounds had been done, and that
is a way for them to just get through what is essentially a difficult job.
The unique thing this work has shown is that there is need to invest in the software strengthening
of human resources, because often what has happened is that a lot of focus has been on
the strengthening of hardware of human resources, so for example, thinking of how to increase
the numbers of nurses within the health system, or how to increase training, but it's a little
bit more about thinking, what does this training mean? So for example, if we are training nurses
are we preparing them for the practical and realistic conditions that they find on the
ground where they don't have enough support and they don't have enough basic resources?
Another potential solution is thinking about task shifting, so from our work there was
already informal and organic task shifting going on, so what lessons can we draw from
that, that can inform a more formal and strategised task shifting strategy, where we can move
some of the non-technical tasks away from nurses, to enable them to actually do tasks
that they have been trained for and tasks that actually reinforce their professional
identity, and then move the non-technical tasks to a lower, more clerical jobs which
can go to a more informal person, where the nurses actually supervise and can support
that person.
I think from this work there is potential to look at nurse resilience, and how that
can be maintained, so for example, from my work, despite all challenges nurses were showing
up for work, and they were still working with poor support and lack of enough drugs and
basic equipment, so there was a passion, they had a passion for what they were doing, so
how do we tap into that intrinsic motivation and maintain it? There are to be more research
that looks into that.
If we think about task shifting we also have to think about, what are some of the regulatory
and governance mechanisms that we need to think about when we introduce a new level
of care? How do you start thinking about integrating into the formal health systems and understanding
that those formal health systems are also complex as they have their own problems? I
see this as ways of thinking ahead in terms of future research in this area.