Nurses fight on the front lines — with no am­mu­ni­tion

Lesotho Times - - News -

PUB­LIC health sys­tems are driven by nurses. Yet, they have lit­tle au­thor­ity. Why do nurses have such lit­tle de­ci­sion-mak­ing power in coun­tries where they drive the health­care sys­tem?

They have huge re­spon­si­bil­ity, but lit­tle au­thor­ity.

I’m one of al­most 5000 nurse-mid­wives in the moun­tain king­dom of Le­sotho. We serve a coun­try of just over two mil­lion peo­ple. Nurse-mid­wives make up 80% of my coun­try’s health work­ers, a 2018 Nurse Ed­u­ca­tion in Prac­tice study found. We’re on the front­line — lit­er­ally.

The 4800 of us make sure 333 000 peo­ple with HIV get the ser­vices they need. This trans­lates to pro­vid­ing an­tiretro­vi­ral treat­ment to just over half of our coun­try’s Hiv-in­fected adults, ac­cord­ing to Le­sotho’s 2014 health and demographic sur­vey.

It’s a daunt­ing task, es­pe­cially when you con­sider how hard hit Le­sotho is by HIV and tu­ber­cu­lo­sis.

We’re the coun­try with the se­cond-high­est HIV in­fec­tion rate in the world. Data pub­lished by Unaids in 2017 re­veal that one out of four adults have con­tracted the virus.

De­spite the coun­try’s ex­ten­sive health prob­lems, it doesn’t have a sin­gle med­i­cal school. All our doc­tors had been trained else­where. For ev­ery one physi­cian in my coun­try, there are about 20 nurses, a 2010 as­sess­ment by the or­gan­i­sa­tion Health Sys­tems has shown.

As a re­sult, nurse-mid­wives sin­gle-hand­edly man­age Le­sotho’s pri­mary health­care clin­ics, par­tic­u­larly in ru­ral ar­eas, where about three-quar­ters of Ba­sotho peo­ple live.

You might as­sume, then, that vet­eran nurses like me can rest easy, if not cel­e­brate what should be an ex­alted sta­tus. That all who are poised to grad­u­ate from the coun­try’s six nurse-mid­wifery in­sti­tu­tions can an­tic­i­pate the se­cu­rity of a ca­reer that of­fers am­ple re­spect and re­mu­ner­a­tion.

But in a coun­try with a nurse-led health­care sys­tem, we lead in ac­tion only.

Let me ex­plain.

We pre­scribe and mon­i­tor the treat­ment for peo­ple with HIV. Yet we’re not al­lowed to switch their treat­ment reg­i­mens.

When pa­tients be­come re­sis­tant to first-line an­tiretro­vi­ral treat­ment, they have to move on to an­other set of drugs, known as se­cond-line treat­ment. But only doc­tors can au­tho­rise this.

Be­cause this process is cen­tralised, and can only hap­pen at district level, it means clients have to book hos­pi­tal ap­point­ments with a doc­tor. Such trips can be dis­tant, time-con­sum­ing and ex­pen­sive.

As a re­sult, some Hiv-pos­i­tive clients in need of se­cond-line treat­ment never ac­cess it.

A case in point is Ms Thabo*, who lives in Makoa­bat­ing vil­lage in the Thaba-tseka district, 280km east of the coun­try’s cap­i­tal, Maseru. She’s a 45-year-old widow with four chil­dren un­der the age of 10. For health­care, Ms Thabo goes to Se­honghong health cen­tre. It’s about 10km from her home.

If she needs to switch HIV treat­ment, she would be re­ferred to Paray Mis­sion Hos­pi­tal. She would have to travel more than 200km to get there.

Who would she leave her chil­dren with? Should she spend the lit­tle amount of money she has to pay for her trans­port to Paray or buy food for her chil­dren?

If we as nurses want more au­thor­ity, we need to ad­vo­cate for law changes. Nurs­ing in my coun­try is guided by the Le­sotho Nurs­ing Act of 1998. It no longer ad­dresses the cur­rent scope of nurs­ing and mid­wifery prac­tice. The 1998 Nurs­ing Act was re­vised in 2016 and be­came the Le­sotho Nurs­ing and Mid­wifery Act of 2016, which gives nurses more au­thor­ity. But it hasn’t yet been in en­acted by Par­lia­ment.

But we also need to change how we learn to nurse.

Un­til rel­a­tively re­cently, nurs­ing and mid­wifery stu­dents re­ceived very lit­tle real-world ex­po­sure to the ru­ral clin­ics and hos­pi­tals where most are de­ployed.

A nurse work­ing au­tonomously in a far-flung clinic — which is the norm — doesn’t have the lux­ury to be “just a nurse”, be­cause she’s also a de facto phar­ma­cist and doc­tor. Stu­dents who are trained pri­mar­ily in large, ur­ban hos­pi­tals – where doc­tors is­sue the or­ders – serve in aux­il­iary roles at the ex­pense of learn­ing to lead.

As a stu­dent in the 1980s, I had the good for­tune to re­ceive mid­wifery train­ing in a very re­mote fa­cil­ity.

Some of my clients ar­rived on horse­back. We re­lied on roja-roja (two-way ra­dios) to com­mu­ni­cate with other fa­cil­i­ties.

One night, I was as­sist­ing a preg­nant woman who gave birth nor­mally. But af­ter the birth, her tummy re­mained very big. Fur­ther ex­am­i­na­tion re­vealed an­other baby — an un­di­ag­nosed twin whose side­ways pre­sen­ta­tion re­quired a pro­ce­dure to ro­tate the baby to a head-first po­si­tion.

I had been taught in the­ory how to do this, but never ac­tu­ally done it. Luck­ily for me, the nurse su­per­vi­sor that night of­fered calm as­sis­tance, al­low­ing me to step to the fore­front. I learned the pro­ce­dure, and I learned how it felt to lead. Hav­ing led this one time left me ea­ger for op­por­tu­ni­ties to lead again.

A com­mu­nity place­ment pro­gramme for nurses, which started in 2011, is try­ing to do just that: giv­ing stu­dents enough ex­po­sure to prac­tic­ing nurs­ing in re­mote set­tings.

The pro­gramme is run by the min­istry of health, the Chris­tian Health As­so­ci­a­tion of Le­sotho and Jh­piego, where I work.

Be­tween April 2013 and June 2014, we con­ducted a study to mea­sure the im­pact of pri­mary health­care clin­i­cal place­ments on stu­dents and pre­cep­tors or su­per­vi­sors. The re­sults, pub­lished in the jour­nal Nurse Ed­u­ca­tion and Prac­tice in Jan­uary, show that these place­ments helped to boost the con­fi­dence and com­pe­tence of nurs­ing and mid­wifery stu­dents.

These fac­tors will likely aid their tran­si­tion into the work­force and per­haps in­crease the like­li­hood for the young pro­fes­sion­als to ac­cept de­ploy­ment to these ar­eas post­grad­u­a­tion.

I sense the pen­du­lum swing­ing back to nurs­ing ed­u­ca­tion prac­tices of decades ago.

El­iz­a­beth Iro’s re­cent ap­point­ment as the first chief nurs­ing of­fi­cer at the World Health Or­gan­i­sa­tion marked the most mon­u­men­tal leap ever in terms of nurs­ing lead­er­ship for the pro­fes­sion.

It in­spired hope that some­day a Le­sotho nurse may loom as large on the world stage as nurses do in our home coun­try.

When he ap­pointed Iro, di­rec­tor gen­eral Te­dros Ad­hanom Ghe­breye­sus said: “Nurses play a crit­i­cal role, not only in de­liv­er­ing health­care to mil­lions around the world, but also in trans­form­ing health poli­cies, pro­mot­ing health in com­mu­ni­ties, and sup­port­ing pa­tients and fam­i­lies.”

That is a for­ward-think­ing vi­sion of global health­care that nurse lead­ers ev­ery­where can re­ally get be­hind.

*Not her real name

The writer, Se­makaleng Phafoli, PHD, is a se­nior tech­ni­cal ad­vi­sor for Jh­piego, an in­ter­na­tional non­profit health or­gan­i­sa­tion af­fil­i­ated with Johns Hop­kins Univer­sity. She is a nurse-mid­wife with more than 14 years of ex­pe­ri­ence as a nurs­ing and mid­wifery ed­u­ca­tor in aca­demic in­sti­tu­tions in Le­sotho. — http://

NURSE-MID­WIFE Se­makaleng Phafoli.

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