Jacob McKnight: Under pressure, the challenges of neonatal nursing
Caring for sick newborns in a poorly resourced hospital is a very challenging job. Yet this is not the only challenge many nurses face as they juggle supporting families and lives in a busy city. Some nurses have developed ways to cope in these difficult circumstances but for many the relentless pressure may cause them harm while upholding the ideals of nursing may seem impossible.
My name is Jake McKnight and I lead the ethnographic elements of the HSDN project. I spent a lot of time in the actual newborn units, trying to understand nurses and having long form interviews with them. We ask them questions about what it is to be a nurse, what they do on a daily basis and the jobs and tasks which make up their daily role.
The particular problem we are interested in is that the nurses as so critical to care for the newborns in these types of settings. There are very few doctors and the time the doctors spend with babies is very short whereas with nurses, they are there for most of the care that is delivered - it comes from the nurses.
The nurses are responsible for ensuring the babies are clean and fed, kept warm which is crucial, and that they get their medications on time. Those things sound quite simple but if you have 40 or so babies, all screaming and all needing attention then there is of course many strains on nurses’ time. Our job was to look at these particular questions and see how nurses make priorities and what they do with very limited resources.
We used ethnographic methods in our research, which means that we spent a great deal of time trying to understand the local culture and practice. Ethnographic methods generally come from anthropology. Traditionally that meant moving to a culture that you did not understand and not many people knew about. Learning the language and understanding cultures and routines and rituals, these kind of things. It is used much more so in this type of environment, in public health where what you have could be considered a sub-culture. You have newborn unit nurses, who operate according to their own rules and routines, and some might say inward facing, and they look to each other for guidance. To understand that you really need to embed yourself within that department and understand how things work.
We used these methods because we are part of a group and we are a multi-method group. Other researchers in the team tend to use more statistical or more quantitative measures to understand where the weaknesses are and to get a numbers-based view of what is going in these wards. But that does not account for everything; it will explain what is going on but it sometimes does not help you understand why things are happening in the way that they do. Ethnographic methods are very good for understanding these ‘why’ questions and why is it that nurses do what they do.
What I can tell you about nurses working in these kinds of environments is that they are very, very busy in a way that you can barely fathom if you are an NHS nurse for example. Some of the things would be very familiar actually but just the scale of them makes it so difficult. For example, a nurse working in the newborn units that we studied might have to sometimes look after up to 40 children, 40 really sick children, whereas the maximum ratio you might deal with in the NHS or another developed economy is perhaps 4 to 1. There is a tenfold increase in what they are asked to manage just in clinical terms.
In addition to that, nurses are busy. Outside of their working environment they may have other businesses, they may be the major earner for their families, they may have lots of dependants who are looking to them for their own education or food, the very basics for living in Nairobi at this time, it is a very expensive city. Then they travel to work, it may take an hour and a half to get across the city, so they arrive tired and then they are faced with this extremely high ratio, and in a built environment which does not really lend itself to a newborn nursing unit. Everything about it is an extreme, relative to what we might see here, and of course they end up quite exhausted by this. They have a limited amount of attention and potentially get very worn down. The phrase they often use is: “Burnt out”.
The first thing we need to consider is alleviating some of these obvious pressures. The ratio is just unfair; it is unfair to the children in the unit and to the nurses who work there - we could really do a lot with that ratio.
Some of the simple things - they call the beds on the wards ‘The King James Beds’ and I asked why? They said all those beds are as old as the King James Bible. They are rusted and clearly not fit for purpose; there are some very simple material things.
Beyond that, I think the whole nursing profession has had quite a hard time in Kenya lately. There has been a series of strikes and scandals, and I think perhaps, trying to increase the motivation of nurses working there, giving them some new resources and training might help raise them up. Of course, the human resource, the help that they so desperately need to get the job done and to feel that they are actually being good nurses and lending the care that these children need.
With regard to research that still needs to happen, I have to say that we have been extremely lucky to date in that we have had such a great opportunity to understand the context of a newborn unit nursing in Nairobi. We richly understand the context and the institutions involved in what it is to be a nurse at this time.
Some of the larger figures - we know that the need is there for nursing, we know there are very few hospitals that are responsible for the vast percentage of overall care through the health system, so there is a real bottle neck around three or four facilities. This research has built a foundation for us to build a new intervention on. In terms of the next research, we really need to take this opportunity to design a new intervention and to implement it.
This interview was recorded in December 2018