Jacinta Nzinga: Understanding nurses’ work to care for sick newborns
To really understand the work of nurses in very busy wards where care for sick newborns is provided, you have to be there. Using detailed observations, day, night and weekends, linked to narrative interviews, the routines, compromises and coping strategies that characterise the delivery of hospital care for newborns are brought to light providing critical information to understand why care is missed and to guide improvement efforts.
I am a Social Scientist, a Health Systems researcher for 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 method we used initially was inviting stakeholders and engaging them in understating what the nursing issues are in the country. These were mainly drawn from training institutions, from the Ministry of Health and from the Nursing Council. We are also doing ethnographic work with front line nurses to understand the culture of nursing 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 is where the 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 we used in this work were ethnographic methods. 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 the 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, over 250 hours observing night shifts, weekend shifts and day shifts. Because we were there for such a long time, we developed close relationships with the nurses. We were able to talk with them informally and keep diaries of this. These were really innovative ways to understand what it means to be a nurse in the newborn units.
The newborn units themselves are small, very congested spaces. In times, they will have anything from 40 to 80 babies but what is more surprising is that the ratio of nurses can be so low. You will have one nurse from 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 there were quite emotional places both for the researchers and for the nurses themselves.
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 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 is 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. Some of the things they were delegating are feeding the babies and cleaning the babies. In some hospitals, mothers were tasked with weighing and keeping feeding charts.
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”. In each typical shift, they would make sure for example that medicines had been given, fluids 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. Often what has happened is that a lot of focus has been on the strengthening of hardware of human resources. For example, thinking of how to increase the numbers of nurses within the health system, or how to increase training. This brings about, what does this training mean? 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 do not have enough support and they do not have enough basic resources?
Another potential solution is thinking about task shifting. From our work there was already informal and organic task shifting going on. 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 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. 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. How do we tap into that intrinsic motivation and maintain it? There are two people from the research looking into that.
If we think about task shifting we also have to think, 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.
This interview was recorded in December 2018