Neonatal nurse Rekha Samant counsels a new mother on Kangaroo Mother Care at the Follow Up Clinic, Kangaroo Mother Care Centre at Seth GS Medical College & KEM Hospital in Mumbai. Photo: Ritam Banerjee/Getty Images for Save the Children
With less than 500 days until the deadline for the Millennium Development Goals, it is an important time to re-evaluate the progress that is being made towards them. The Millennium Development Goal 4 (MDG4) sought a two thirds reduction in deaths of children under five years of age by 2015, which India is likely to miss. To achieve success in reducing infant mortality, it is essential that quality clinical care be provided and that qualified, well-trained healthcare professionals are available. India is faced with inadequate numbers of competent nursing professionals in service, and a lack of opportunities for the next generation of nursing professionals to contribute towards improving newborn health due to unstructured teaching curriculum.
Nurses play a pivotal and varied role in many developing countries’ healthcare facilities, including providing prenatal education, labor and delivery, and ongoing newborn care. Most notably, it is nurses who are providing skilled attendance during birth, performing newborn resuscitation, initial newborn care, stabilization of at-risk and sick newborns, and determine the need for transfer to regional hospitals when necessary. In addition, nurses provide counseling to mothers about the importance of instituting kangaroo mother care and breast feeding as well as the special needs of low birth weight babies. Due to a shortage of physicians, especially in rural areas in developing countries, the nurses’ role is especially critical at district, sub-district areas, and villages. Although these nurses generally have a collaborating physician in a regional centre (often located more than an hour away), they generally practice alone in these local care facilities and Special Care Newborn Units (SCNU’s), conducting newborn deliveries and treating at-risk and sick babies brought from the community. Despite these expectations from nurses, strategies for their educational preparation and resources for ongoing learning is varied and often limited.
In a recent paper by Campbell-Yeo and colleagues, a structured evaluation of the identification of the barriers and facilitators for the education of nurses in the care of at-risk and newborn babies in India was conducted. Campbell-Yeo et al. (2014) held twelve Focus Group discussions (FGDs) involving 101 health care providers from facilities that provide various levels of newborn care across three Indian states. The majority of participants were female (97/101) and most of the female participants were nurses (82/97): 10 were Auxiliary Nurse Midwives (ANM’s), 3 were physicians and 2 self-identified as other (administrator or accredited social health activist). Through the FGDs, the nurses identified several challenges they faced related to access to resources, limited manpower, and system limitations. In addition to challenges, nurses also identified learning needs related to clinical skills and basic management, including resuscitation, immediate stabilization of sick newborns, ongoing clinical care and correct use and maintenance of equipment. It was suggested that joint inter-professional educational opportunities and efforts to enhance working together would be extremely beneficial.
The nurses also identified potential solutions to the above mentioned challenges, including the need for all new nurses to receive a structured and standardized orientation program to ensure a minimum level of competency; ongoing competency evaluation; the identification of persons (preferably nurses) to coordinate educational opportunities at pre-service, in-service and on an ongoing basis; less movement of nurses with an increase in permanent jobs; and incorporating learning opportunities that are easily accessible and financially feasible. Across all levels of neonatal intensive care units (NICUs), the greatest resources that nurses identified were experienced nurses and doctors who could teach and share their knowledge with others.
Based on dialogue with nurses and stakeholders, the findings of this study provide valuable insight into the current healthcare system in India with specific reference to the nursing care of at-risk newborns. Several goals were developed to improve nursing and health policies, both in India and other countries. The study suggests a five-pronged approach necessary for the successful training of nurses in newborn care to improve child mortality outcomes:
- The first is to identify and evaluate existing resources that can be utilized.
A second is to standardize the orientation curriculum for the care of sick and at-risk newborns to ensure nurses are adequately trained in addressing the critical needs of at-risk newborns.
- The third is to institute learner-based continuing educational opportunities and ongoing competency-based evaluative programs that are easily accessible as part of work environment.
- A fourth is to incorporate mechanisms for sustainability in training programs, such as creating a centre of nursing excellence (train-the-trainer) with designated central and local nursing positions responsible for education.
- And fifth to invest in structured curriculum for pre service education of future nurses.
Investments in nursing is all the more important as staff nurses were identified as one of the important service providers to deliver the recently launched India Newborn Action Plan (INAP). According to INAP, nurses are critical for six strategic intervention packages, namely pre-conception and antenatal care , care during labor & childbirth, immediate newborn care, care of the healthy newborn, care of small & sick newborns and care beyond newborn survival. INAP spells out six key principles to achieve its targets including quality of care around the time of birth, convergence, partnerships and accountability. It will focus on equity and eliminating any gender-based differences in health care.
Overall, the findings from the study by Campbell-Yeo et al (2014) provide some significant revelations in terms of the barriers that nurses in India face when providing care in rural areas to sick and at-risk newborns. By having the nurses also identify facilitators and potential solutions to the barriers, the paper also offers important information related to the direction that needs to be taken to improve the training and resources available to nurses. Without providing support to nurses in rural areas, the struggle to reach the MDG4 of reducing infant mortality will not be reached in India.
The findings of Indo-Canadian Shastri project supported by a matching grant from the WHO SEARO, New Delhi, were shared at a stakeholders meeting attended by key partners (USAID, NIPPI, East Meet West, UNICEF, Indian Nursing Council, Indian Association of Neonatal Nurses, JHPEIGO and others). We hope that policy makers, nursing leaders, neonatologists, academicians, and interested stakeholders will work together to improve the unmet needs of our nursing colleagues to enhance the quality of care provided to at-risk and sick newborns in India.