The senior Nurse who played a crucial role in ensuring that the conjoined twins’ surgery in March 2021
Sr Ajilong Jennifer Juliet, Assistant Nursing Officer, Soroti Regional Referral Hospital
The Nurses and Midwives Letter Issue 9
THE NURSE & MIDWIVES LEADERS’ THINK TANK Year of the Health and Care Workers 2021
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TABLE OF CONTENTS CHIEF EDITORS NOTE BY COMMISIONER MUSEENE ................................................................................................................ 3 NURSES AND MIDWIVES AS CRITICAL MEMBERS OF CARE TEAMS: THE CONJOINED TWIN SURGERY: THE CRITICAL ROLE OF NURSES AS PART OF THE CARE TEAM..................................................................................................... 4 COVID-19 CHAMPS: NURSES AND MIDWIVES LEADING THE VACCINATION CAMPAIGN ............................................ 10 5 MINUTES WITH A LEADER: PSYCHOSOCIAL CHALLENGES FACED BY NURSES AND MIDWIVES DURING COVID19 PANDEMIC ..................................................................................................................................................................................... 13 AFRICA AND THE NURSING CRISIS .............................................................................................................................................. 17 RESOURCE LIST FOR NURSES AND MIDWIVES......................................................................................................................... 19 LEARNING OPPORTUNITIES AND ACADEMIC RESOURCES ................................................................................................... 19 NMLTT ON GOING ACTIVITIES ...................................................................................................................................................... 20
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CHIEF EDITORS NOTE BY COMMISIONER MUSEENE It is always a great pleasure for me to speak to you through these introductory messages. I thank God who has kept us alive, healthy and made us able to serve humanity. I feel privileged to share with you the joy of various achievement made by nurses and midwives. I appreciate nurses and midwives across the globe who have continued to serve in various capacities and settings. Many are serving in Hospitals, Clinics, Communities, Educational institutions, and Ministry departments and Directorates. Thank you for the continued service delivery at your various stations, patient care provision, teaching of nursing and midwifery students, and successfully celebrating the International Nurses Day and International Midwifery Day despite the COVID-19 era. In this COVID-19 era, updating our competencies is more needed than before; I challenge you to improve your skills continuously. Read and research to improve your knowledge because medicine, nursing and midwifery are dynamic, and new diseases are being discovered every day. Ensure that you practice what you confidently know. Where you are in doubt, please, do not hesitate to consult. Be sensitive to the current epidemic’s challenges and be aware that the rest of the other disease and conditions are still significant. Please be the health workers that our country and the globe need; full of ethical values and commitment to serve and drive the national and international health agenda. I look forward to a country with skilled nurses and midwives and a productive, healthy population. Thank you, For God and My Country. By Dr. Safinah Kisu Museene (Ph.D). Chairperson, uganda nurses and midwives’ leaders thinktank and Commissioner, health education and training, ministry of education and sports
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NURSES AND MIDWIVES AS CRITICAL MEMBERS OF CARE TEAMS: THE CONJOINED TWIN SURGERY: THE CRITICAL ROLE OF NURSES AS PART OF THE CARE TEAM An Interview with Sr Ajilong Jennifer Juliet, Assistant Nursing Officer, Soroti Regional Referral Hospital. The senior Nurse who played a crucial role in ensuring that the conjoined twins’ surgery in March 2021 at Soroti Regional Referral Hospital was successful.
1. Please tell us about yourself? My name is Ajilong Jennifer Juliet. I am an Assistant Nursing Officer. I am a single mother with four children. I love God, and I love my profession. I started as an enrolled nurse obtained from Soroti Nursing School in 1993. I then went on to do my diploma in nursing in Mulago in 2000. I have been working with public service since 1995. I have also worked at nursing training schools as a clinical instructor. I did this in Mbale School of Nurses, during which time I was given an appointment to work at Soroti Hospital. At that time, it was a district hospital. I have worked mainly in theatre but have worked in the medical ward for two years and in Pediatric Ward for six months. I am also the clinical instructor at Soroti Nursing School, and I teach Nursing theory and practice.
2. What drew you to the nursing profession? •
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Several factors drew me to the Nursing Profession. As a young girl, I used to see people getting sick and not getting the help they required. I once got a mother delivering at home, and I helped them. We did not have what to use, but a good Samaritan gave us a blade to use. By God’s Grace, the baby was delivered, wrapped up in clothes, and I asked them to go to the hospital. I had to rush and go to school. This experience tortured me since I did not have the skills required to help. This drew me to become a midwife. I had applied for midwifery and did the interviews. However, when I went to the Soroti school of nursing to find out if I had been taken, I found myself on the list for nursing. I was content with this because it was still in the health profession. Another experience I had was with my uncle, who used to inject us when we were sick when he was not a health professional. I was encouraged to do this so I can also help my family members. However, we still make fun of this when he is sick, and I have to give him any treatment, and he says I am revenging. While in secondary school, I used to see nurses from the nursing school who were very smart in their uniforms. I remember the midwives used to dress in purple. This also encouraged me to join the profession to be as bright as the nurses I had seen. 4
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The Soroti A-Team
Photo credit: Dr, Claire Nakubulwa
3. What is your most significant achievement to date? •
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Whenever I see my patients getting better, I feel a sense of satisfaction and joy. That is my most outstanding achievement; seeing my patients recover. Sometimes we get patients to come to the brink of death, and as a nurse, you do all you can just to get them through the day. So, seeing a patient recover brings me joy and is an achievement. This recent admission challenged me. I was the nurse on duty when they came into the hospital. We thought a referral might be the best option, but the mother was poor. She did not have money to go to Mulago, so as hospital staff, we had to collect money to send them to Mulago until we were successful. However, I was told that they had returned to Soroti, and I felt so bad. It was tough seeing the other baby struggling to breathe as the other twin was dead. Every time I would sleep, I saw the image of this baby struggling to breathe. I told my colleagues, including the surgeons, that we needed to operate on this baby. I discuss freely with the surgeons, and we have a good working relationship. I was thrilled when my colleagues agreed that we should operate on the twins. This, I can say, has been one of my most outstanding achievements. We decided to do something about it. Another achievement I feel was working at Soroti Hospital during the War. I was working in theatre. Operations were endless due to emergencies due to gunshots. We would work all day without lunch and not even realise that the day is gone.
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I was also among the first nurses to work on the Covid unit because others were shying away and feared getting sick. I decided to do this because if I did not offer myself, who would take care of these patients. I thank God that I worked there for a month and God protected me, I did not get sick, so I was pleased about this recognition. Overall, I can say that my most significant achievements are when I nurse patients to recovery.
The Team Being Recognized at Parliament
Photo credit: Dr. Claire Nakubulwa
4. How do you prefer to receive recognition? Publicly or private and why? •
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Public recognition is good so that the public knows the good things that we do. For example, there is a lot said about health workers that we are rude and get money from patients. So, I want the public to know that it is good in the hospitals. Some people don’t want to come to the hospitals and instead go to clinics, then come to the hospital. So public recognition is good for the public to know that it is good in hospitals. Another good thing about public recognition is that it encourages other colleagues as well to do better. I am grateful to the Nurse leaders Think Tank that has looked for me and recognized me. It’s good that we are recognising each other.
5. You were involved in the recent ground-breaking surgery in Soroti RRH conducted on conjoined twins, and one of the twins had died. How did that make you feel, and why? As I mentioned earlier, we first referred the patient to Mulago. This was a young mother who was not stable financially. We had to collect money to send her to Mulago, but then they returned to Soroti. I convinced my 6
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colleagues, including the surgeons, that we should try our best to help the baby. Even if the baby does not make it, we would have tried our best. When they all agreed to work on the baby, I was relieved. I ensured that everything that was needed was ready, blood was available for the baby. Of course, we ensured we had two units of the baby’s blood type even if the baby required less, but we wanted to be sure that we were prepared in case of anything. I was the instrument nurse for this surgery. The senior surgeon, Dr Joseph, worked with another surgeon, and I provided instruments to the surgeons as they carried on the surgery. It took about 2 hours. We started at 11, and about 1:30, we were done. It was mainly the sternum and lower lobe of the liver that were affected. That is why it did not take so long. We all felt delighted after the operation. We ensured that the baby recovers from General anaesthesia before taking them to the ward. When we took the patient back to the ward, everyone was happy, including the patients on the ward. They all clapped and were filled with Joy seeing the baby come back from the operation. As a team, we check on them every day, monitor them to ensure the baby is stable. We also counsel the mother and giving the necessary support with the social issues she has. We have had to buy some items like soap, clothes for the baby, among other things. As hospital staff, we had to make some contributions from our pockets. However, the hospital director has put aside some money to take care of the baby right now. A group of Teso doctors has made some contributions and is sending one of the surgeons to support the mother. This has been one of my most outstanding achievements, given the condition the baby was in.
6. As a nurse who participated in this surgery, what was your role? I was the instrument nurse; I ensured that we had all the supplies required, including the instruments and blood. I also ensured that the theatre was prepared; we had just had another surgery, so we had to prepare quickly for this one to take place. I also confirmed that the personnel were all available for this operation.
7. What is the role of nurses in the pre-and post-Operative care of surgical patients, especially with such complicated procedures? Nurses ensure that patients are stable pre-op by monitoring vitals and ensuring that the patients are ready for the procedure. The nurse has to create rapport with the patient when they come into the theatre, ensure that it is the right patient for the proper technique. If there is any required treatment that may not have been given in the wards, we can also give it. If we see that a patient is not stable, we can take them back to the wards to be counselled until they are ready. So, we keep monitoring their vitals. Nurses play a significant role in ensuring that patients recover and are stable Post-Op, maintaining the airway and monitoring vitals until the patient is fully recovered. We then hand it over to the surgical unit nurses to continue care. We have to hand over patients who have fully recovered. 7
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During the operation if patients are awake, e.g., when they receive spinal anesthesia, continue engaging until the operation. The instrument nurse is the one who ensures that the surgeon has the instruments; in case things are not available, there is the runner nurse to avail these. We can also give a hand in the procedures, share best practices with the surgeons. I have done this in some cases, and some surgeons/doctors take my advice while others don’t. If I see that things are not going well, I can call one of the senior surgeons. The surgeons I work with are outstanding and they always respond to my calls and recommendations. Some may not want to listen to me, thinking that “what can a nurse teach me?” So, I usually advise them which instruments to use on what tissue and so on.
Nurses Being Recognised at Parliament.
8. What is your message to nurses out there? •
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My message to the nurses is that I urge my colleagues to be kind and have the heart of loving our profession. We should show people that when they get nursing care from us, they know they have been cared for by knowledgeable and kind nurses. Nurses should adhere to our ethical code of conduct – avoid being rude to patients. I always advise my colleagues who may complain that the salary is negligible, but we have to always have the heart for helping patients no matter the circumstances. We always have to be available and approachable to our clients. 8
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9. How can policymakers and government support you better deliver quality nursing care to the patients you serve. • •
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More nurses in Health Facilities are few on the ground, and this leads to nurses getting overwhelmed. if we are many, we divide the roles, and we work better. Improve on Equipment and resources, including personnel at the hospitals. Soroti RRH operates about 200 patients per month. It serves the Teso region and beyond. However, the theatre is small, and some equipment is not available. There only two nurses in the theatre, and when one is on leave, you have one nurse working alone. We are supposed to have 5 Anesthetic officers, but we have 3. This leads to having one Anesthetic Officer serving more than one patient at once. One can work for two weeks without leave. Better pay for health workers and improve working conditions for personnel, such as providing lunch so that health workers don’t have to go out to look for lunch. When we go out, patients complain, and yet you can’t work on an empty stomach. Politicians should leave health workers to do their work. Drug stock-outs, politicians, can make noise without understanding which drugs. Improve on supplies, for example, gloves – we recently got only size 7. Some staff use 7.5, so this is a problem. They ask me to do something, but I cannot buy gloves all the time. So, government bodies should provide supplies as ordered. Too many Attendants and in this time of covid its more dangerous– when you tell them to go away, it’s a problem – they go to media and politicians and complain. Colleagues got covid, better policies for managing occupational hazards and staff who get sick while on duty.
10. Any last words of wisdom • • • • •
Appreciate the government of Uganda for the work done. We now have stability; we are not getting many gunshot wounds in the hospital as before. Nurses Thinktank, it’s great that we recognise our work. When we realise ourselves, it’s a motivating factor for others too. Let us be vigilant, update ourselves with knowledge and skills for the good of our patients, Urge the government to treat all hospitals equally and equip Soroti regional referral hospitals to manage patients within the region. It’s a way of decongesting the national referral hospital. Covid has highlighted the need to have well-equipped hospitals – the rich stayed with the poor since they could not leave the country.
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COVID-19 CHAMPS: NURSES AND MIDWIVES LEADING THE VACCINATION CAMPAIGN
COVID-19 VACCINE CHAMPIONS One by One Makes a Herd
Uganda has Covid-19 vaccines to cover only 1% of the populations, says Christine Ramo, NBC news (May 11th, 2021). Can we afford to waste even one dose? We need champions to overcome vaccine hesitance. Nurse Natalie Victa prepares to administer the Covid-19 vaccine on Namatale Island, distributed by UNICEF Photo Credit: Christine Romo / NBC News (Romo, McFadden and Talmazan, NBC News, May 11, 2021)
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Know More. Become a champion. Visit the MoH website for more information
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Ensuring the Public is Well Informed
ction? e or fi Scienc
you are.
Learn the Facts. Separate science from misinformation. If in doubt, seek more information. The Vaccine Confidence Project has some useful information.
One Person at A Time Makes a Herd
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5 MINUTES WITH A LEADER: PSYCHOSOCIAL CHALLENGES FACED BY NURSES AND MIDWIVES DURING COVID-19 PANDEMIC Psychosocial challenges, refer to the negative impacts imposed on an individual when both psychological and social needs are not met or fulfilled as expected. The psychosocial effects are felt on both the mind and body. The reason is sophisticated and hypothetical, and its response depends on external environmental stimulus. For example, when information is pleasant to the individual, it responds positively, but when it’s unpleasant, it reacts negatively. Similarly, when needs are fulfilled, it responds positively; however, it responds negatively if demands are not satisfied. However, this also depends on the individual’s mechanisms of coping and resilience. People with solid strength quickly overcome challenges. Those with weak power find it hard to manage, experiencing mental health symptoms such as stress, depression, anxiety, phobias, panic, unresolved persistent physical symptoms, and other mental disorders. The Nurse or Midwife has a mental aspect of health that can be affected by her nature of work; if this is not resolved, it can affect his/her psychological and social functioning. Psychologically the Nurse/Midwife may develop disturbance in thinking, reasoning, decision making, perception, and behaviour. It can also lead to dysfunction in work, relationships with colleagues, friends, family members, and level of cooperation. If the Nurse/Midwife can adjust, she/he can deal away with the situation but, if not, may develop mental health problems that require intervention. Psychosocial challenges faced by Midwives/Nurses during the covid-19 pandemic. The pandemic has not spared health workers of the effects of Covid-19, especially the psychosocial challenges that have significantly impacted their lives. These include:• • • • • • • • • • • • •
Persistent fear of contracting the disease. Nightmares and terrors Anxiety Psychological nervous loss of appetite Depression Stigma Discrimination Mistrust by family members due to the nature of their work Unstable family relationships including divorce due to the nature of her work. Self-blame for the death of patients. Failure to attend to their families socially. Increased workload due to managing patients with multiple problems/conditions. Failure to provide psychosocial support to others. 13
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Danger mental-health signs to look out for in a Nurse or Midwife • • • • • • • • • • •
Unprovoked anger and irritation Reduced productivity at work Absenteeism Isolation or reduced level of socialisation Tearfulness or persistent sadness/depression Unexplained fatigue, headaches, loss of appetite, loss of libido Reduced sleep Persistent nightmares and terrors Swing of moods Unusual or odd behaviours High levels of stress
Available resources to support Nurses/Midwives. i. ii. iii. iv. v. vi. vii.
Peers Fellow workmates Counsellor Supervisors Psychiatric Clinical Officers Psychiatrists Psychologists
How can managers support Nurses/Midwives better to avoid breakdown? • • • • • • • • • • • • • • •
Managers should learn to be supportive to the upcoming nurses/midwives. Conduct individual/group meeting to discuss issues related to work, especially during the pandemic. Managers need to have a listening ear and be effective communicators. Acknowledge and appreciate the work of midwives/nurses by motivating them, giving social praises, study leaves, duty offs, lobbying for more staff, risk allowance, and salary, flexibility on shifts of work. Inculcate in nurses/midwives the culture of sharing in times of happiness and sadness. We are learning each nurse/midwife’s character and attitude to work. Provide talking messages on covid-19 of hope and encouragement in the ward. Ensuring free screening tests for covid-19 for Nurses/Midwives Provide time for relaxation on the ward Reduce workload by planning and advocating for more workforce Encouraging further post-basic training Continuous provision of guidance and support on the use of SOPs Console, comfort, and counsel those in need Motivate staff recognition of her exemplary services Understand each staff as a person 14
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Early identification and referral of nurses/midwives with mental health problems to specialists Engage staff in planning for activities of the ward and avoid dictating unless were necessary. Be close and accessible to the midwives/nurses to build a good working relationship. Managers should be fair and exercise justice to all staff.
By Harriet Kwagala, Mental Health Nurse
Covid-19 Vaccine: Let Us Lead by Example
Lead By Example: PS. Diana Atwine Receives Her First dose. Photo Credit: MoH
8 When it comes to the Covid-19 vaccine and adherence to the public health measures, we need more leaders than bosses
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I tell you what? When it comes to the Covid-19 vaccine and adherence to the public health measures, we need more Leaders than Bosses Bosses
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Image Credit: John Lester
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And we Need Herd Immunity
AFRICA AND THE NURSING CRISIS The COVID 19 pandemic that has put the entire globe on its knees amidst the already existing health care challenges has posed an overwhelming demand for nurses world over. Nurses have been so pivotal in the prevention and treatment of COVID 19 patients on the ICU beds and many have also succumbed to the disease in line of duty. With the current COVID 19 pandemic and its severity in many of the high-income countries, the numbers of nurses migrating from Africa to practice in the western world is expected to exponentially grow. With many of the African countries still struggling with shocking shortages of nurses, poor working conditions, low salaries for nurses, the current trends in the global demand for nurses is set to devastate such health care systems even further because of the likely increase in the international nurse migration and mobility. According to the State of the World’s Nursing 2020 Report that was recently published by the World Health Organization and the International Council of Nurses (ICN), there is significant reliance on foreign-born nurses in high-income countries, where 15.2% of nurses were reported to be foreign born or foreign trained. The global shortage of nurses is estimated to be 5.9 million with over 89% of this shortage concentrated in lowand middle-income countries where the growth in the number of nurses is barely keeping pace with the population growth. In many African countries, the nurse – patient ratio is several times a multiple of the WHO 17
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recommended nurse – patient ratio of 3:1000. In a country like Uganda, the ratio stands at 1: 11,000. Such trends jeopardize the implementation of quality nursing care yet nurses play a critical role in primary health care that encompasses prevention and management of communicable and non-communicable, emergency preparedness, patient safety and delivery of integrated people-centered care. Although African countries are striving to train more nurses, they are still challenged with the ever-growing numbers of locally trained nurses migrating to practice in higher-income countries in America and Europe that produce low numbers of nurses vis-à-vis the demand of nurses within their health care systems. Such countries have the capacity to employ and offer better and attractive pay packages to foreign nurses from low-and middleincome countries. This is further exacerbating shortages in many African countries. As we celebrate this year’s international nurses’ day, African countries need to take keen interest in the current and future shortage in the nursing workforce and intensify efforts to bridge the gap. There is need to invest more in nursing education through increasing state sponsorship for nurses at all levels to increase the number of nurses annually produced. Of recent, there are many nursing training schools opening up thus the need for close supervision and regulation to ensure that the nurses produced have the knowledge and skills to meet the local and global health demands. Devise strategies to attract, increase recruitment and retention of locally produced nurses or else, Africa will continue training nurses for the rest of the world. Governments need to invest more in improving working conditions, increasing salaries, and creating professional development opportunities for nurses. Professional development will enable advanced practice nursing roles and quality nursing patient care. However, in a country like Uganda, specialized nurses have not been given the due attention and not allowed to practice to the full scope of their training. On the other side, many enrolled nurses in public service have individually invested in their professional growth and training to acquire diplomas or even degrees but are still recruited and serve in capacities of lower cadres. Advanced practice nurses when supported and enabled to practice to the full scope of their training and skills can greatly increase access to primary health care even in the rural and remote areas. Its time nurses participated in decision making since they play an influential role on the effectiveness of health care system. With the ever-increasing international mobility of nurses, African countries ought to establish partnerships with international regulatory bodies to monitor, govern and regulate the exportation of nurses. These will help to mitigate the excessive loss of their locally trained nursing workforce to the international labor market. The authors are nurses based in Uganda. Lubega Martin is a BSN nurse and Author-My Pregnancy Handbook Lilian Nuwabaine Luyima is a specialized midwife (BSN, MSN-Midwifery & Women’s Health; CPD Coordinator Aga Khan University-Uganda)
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RESOURCE LIST FOR NURSES AND MIDWIVES Please find below a list of useful contacts to forward your concerns appropriately. UNMC queries:- info@unmc.ug UNMU:- info@unmu.ug CPD APP concerns: martin@unmc.ug National organisations Education and training Standards:- Department of Nursing at Ministry of Health BTVET (Min of Education and sports) QUESTIONS? CALL: 0417 893600 (PRO) Mobile 0777108170 Benevolent fund:- Department of Nursing at Ministry of Health, Uganda Some of the associations AGNMU: graduates@agnmu.org Critical Care Association:president@ccnau.org Midwifery Association: nationalmidwivesassociationug@gmail.com Nursing and Midwives Society: info@nursesandmidwivessociety.org Emergency Care society of Uganda:- admin@ecsuganda.org Palliative care Association of Uganda:- pxau.admin@pcau.org.ug Others NMLTT (Think - Tank Leaders):- uganursemidwife.leaders@gmail.com Writing articles for publication on NHCC Uganda website:- editors.nhccuganda@gmail.com Global networking Nursing Now Campaign Uganda:- nursingnowuganda@gmail.com
LEARNING OPPORTUNITIES AND ACADEMIC RESOURCES OFFER Access to Health Care journals (Discounted at 30%) In partnership with Uganda Nurses And Midwives Association- UK (UNMA-UK), Markallen group UK (https://www.markallengroup.com/ma-healthcare/) has offered a 30% discount on their online subscriptions (MA Healthcare titles only) for UNMA-UK members. This has also been extended to Nurses and Midwives in Uganda as per UNMA-UK mission. Use the confirmed discount code [UNBA30] to access a range of their healthcare journals. 19
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NMLTT ON GOING ACTIVITIES NMLTT continues to work in collaboration with the National Task Force in the Management of COVID- 19. The Think Tank Newsletter editing team accepts articles on a rolling basis under the sub themes below. • • • • •
Research and Innovation Continuing Professional development (CPD) Policy Leadership/Governance Clinical Practice Covid-19 Response.
The Think Tank will resume the regular meetings soon to check on progress and formulate strategies to support and advocate for Nurses and Midwives. We would like to thank Seed Global Health for the continued support for hosting our zoom meetings and webinars. We urge all nurse leaders to attend the meetings. Please send us your current email address in order to be included in a timely manner. Our faith in you is steadfast. May you continue to rise up to the challenge in this International year of the Health Care Worker by WHO - 2021. More than ever, this nation needs you. We thank you and May God bless you. Please feel free to contact us with your concerns. If you find this Nurse & Midwife Letter useful, we would really like to hear from you. We continually evaluate and assess the progress of our communication channels with you. Please email us at the address above. Copy to:
The Hon Minister for Health The Permanent Secretary, Ministry of Health The Ministry of Education and Sports The Chairperson, NATIONAL TASK FORCE COVID 19 The President of Uganda Medical Association Commissioner Nursing Services, Ministry of Health All Nurses and Midwives in Uganda
Compiled and Edited by Think Tank Debrief Team on behalf of NMLTT: Dr Rose Clarke Nanyonga, Elizabeth Pearson, Irene Atuhairwe, Tracy Kobukindo, Judith Hope Kiconco, and Sr. Christine Alura. Chairperson: Dr. Safinah Kisu Museene Informed disclaimer:- All editing team members are Nurses, and they are all volunteering their time and expertise. However, the views expressed in the articles are of the authors or writers solely. Although the editing team does the very best and is responsible for vetting the information, the authors’ opinions remain. It is, therefore, upon the authors to make sure that what they submit is referenced appropriately and accurately.
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