Nursing/Midwifery Report 2011


 St Mary’s Hospital, Isle of Wight (UK)-Juba Teaching Hospital Link




4th-20th November 2011

Report to Dr Samson Paul Baba, Director General Planning and Coordination, Ministry of Health, Juba South Sudan.

Juba Teaching Hospital (JTH) is working to improve services after 21 years of war.
This report was written at the request of Dr Baba to highlight areas where improvements are required to raise the standard of care at JTH. Dr Baba’s request was made to the Jubalink team visiting Juba teaching hospital in November 2011. Juba Link is a charity which provides a link between St Mary’s Hospital Newport Isle of Wight UK and JTH. The aim of the charity is to provide Medical and Nursing/Midwifery education to JTH.

The following recommendations are intended to be helpful in working to raise standards on ward and out patient/emergency areas. The report is not comprehensive as it is made up of first impressions only. A more detailed study is required to provide detail.

It is clear that there are some very committed professionals at JTH and the nursing and midwifery staff are keen to learn and improve standards.
There are some excellent senior nurses who have potential to teach and facilitate others and so improve standards. My thanks to Janet Michael Director General Nursing and Midwifery for arranging the team visit to JTH, Dr Wani Mena CEO and Matron for enabling a Juba Link team to visit the hospital and work with staff. Thanks also to Sister Petronella Wawa Principal of the College of Nursing and Midwifery for the opportunity to teach the excellent students of the college who have real potential to be advocates for high standards of nursing and midwifery practice in the future.
Staff work under very difficult conditions due to poor staffing levels and training, inadequate infrastructure and equipment.

This report recommends changes some of which will require significant funding to provide patients with a reasonable standard of care.

Infrastructure and equipment.

There are some examples of fairly well equipped areas such as the dental department that were visited. Other areas require infrastructure improvements and equipment if the hospital is to be able to provide a higher standard of care to patients. The report includes notes on the dental department, which indicates that standards there are reasonable however risks to patients are noted.

The following was noted on the visit to JTH November 2012 and it is recommended that consideration is given to prioritising funding for these areas of need:

• The outpatient/emergency department has no wheelchairs and in consequence patients are carried in by relatives if they cannot walk.
• There are few trolleys to take patients to wards if they cannot walk.
• There is no intensive care unit or coronary care unit and people pass away in the emergency department for lack of these services.
• There are few gloves and none when they run out, and so staff and patients are at risk of cross contamination from bodily fluids and infection.
• There is a severe lack of cannulae, syringes, catheters, naso gastric tubes, dripsets, dextrose, ringerlactate and other IV fluids. Sometimes there is a lack of material to use for dressings and where there is dressing material the autoclaving system is slow, therefore some dressings are not sterilised.
• The bed linen is in short supply and the service from the laundry cannot keep place with demand, hence relatives are asked to bring in bed linen. Laundry takes 2-3 days to come back to the wards. Once this is soiled relatives have to wash and dry it in the grounds of JTH. This leaves beds in disarray with some patients on bare mattresses.
• The mattresses are in poor condition with tears in their fabric and so are not easily kept clean; therefore there is a risk of cross contamination. Some beds are in very poor condition.
• Wards look haphazard and in a state of disrepair. For example paint is chipped and dirty on walls and doors.
• There are very basic facilities for hand washing on wards, hand basins are chipped and running water is not always available
• There is a lack of antiseptic liquids. Sometimes there is no chlorine available for cleaning
• There is a lack of pain relief medication and some patients have dressings changed for example on amputations without pain relief and are consequently in severe pain.
• There are few oxygen cylinders. For example there is one on the neonatal nursery and so when there are several babies, staff have to choose who benefits from the use of oxygen. On one of the days when visits were undertaken there was only one oxygen cylinder for the whole of the general part of the hospital.
• Sphygmomanometers are available in the outpatients department and some wards. However they are taken to other wards by staff and not returned and so blood pressure recording is haphazard.
• Suction machines are broken across the hospital.
• There is no heart monitoring equipment
• There are no ECG machines. Patients with severe chest pain die and will not have had an ECG.
• There are no defibrillators.
• There are few nebulisers, ambubags and airways.
• There are no spinal collars in the emergency department to save life and prevent spinal injuries from exacerbation. There appear to be many road traffic accidents and their early treatment may be compromised because of lack of equipment

Report on the Dental Maxillofacial Department as an example of improved standards with remaining risk areas:

Generally compared to other departments the clinical area is good, and instruments and drugs are stored in lockable cupboards. There are four workstations in two surgeries, two for maxillofacial treatment and two for dentistry. There are problems with lack of instruments, no suction and cross infection control
Instruments and equipment including syringes are being reused after only being wiped with methylated spirit, there is one syringe per workstation as opposed to one per patient. The method of cleaning all hard surfaces is methylated spirit on cotton wool.
Dirty instruments are cleared away by the clinician and left on the side, As there are only one or two nurses who are general nurses rather than dental nurses, the instruments can stay there a long time, and are often just wiped and put back This includes reamers for root canal treatment, and the same equipment is used for multiple patients.
The workstations need regular maintenance. Two were without working lights and there is no suction despite the suction units being attached to the stations. Surgical procedures were being carried out without light and suction and therefore no assistance which is detrimental to the patient and the surgeon.
There is a sink with running water in one of the surgeries but no provision of hand towels so hands are wiped on clothes.
Staff are requesting training in cleft lip and palate surgery on site, maybe a surgeon and assistant returning to train clinicians and assistants. There had been a charity visit to JTH the week before undertaking cleft lip surgery. Dr Joy had been in theatre with them and felt that if the staff are trained in the hospital then they will be able to offer this service on a regular basis greatly enhancing the quality of life for the patients who are often shunned or kept out of sight due to facial disfigurement. Staff at JTH feel that there is a need to access post graduate education in Maxillofacial Surgery in the UK. One of the dentists was very keen to develop his skills further.

Overall the service being offered in this department is good but could be so much better, with more training, more equipment/instruments and trained dental nurses that can also assist in theatre,. Nurses in the dental department are motivated have some very good skills and are keen to learn.

Clinical care at JTH.
Due to the lack of triage in the outpatients/emergency department, patients who are very sick wait in line until their turn to be seen. This means that they are sometimes there for many hours and then have to await laboratory tests prior to being treated. This may exacerbate their condition or they may wait until treatment is too late.
There is the potential for infectious diseases to pass from patient to patient in the OPD/ Emergency department where vomiting is not uncommon.
The Juba Link team were informed that children’s wards care for up to 100 children at night and there may be up to 4 children per bed. Lack of staff able to care for this number of children, means that some children do not get their medication and receive only scant care at night. This may add to the high levels of mortality.
There is a need for education for midwives on resuscitation of the newborn as infants are especially at risk of hypothermia.
Medication is missed on wards both during the day and at night time. Nurses must be made accountable for the giving of medicines.
There are few thermometers. They are of the old mercury type in the main and so breakages occur without replacement. Digital thermometers would give more reliable readings.
Patients deteriorate because staff do not take observations of vital signs on many wards where they are required to detect deterioration and so alert medical staff.
There is no privacy and dignity for patients as beds are close together and there are few screens.
Medication does not tend to be locked away and the lack of needles means that the same needle may be used for more than one patient and there is an acknowledged risk of medication errors and omissions
Diabetic patients can wait up to 24hrs to obtain blood sugar results as there are no glucometers that work, available, (partly due to lack of testing strips). The result of this is that patients may die of ketoacidosis while waiting for results and treatment
There are no cleaners at night and not enough night staff and so vomit for example may remain on the floor until day staff arrive.

Mental Health
A separate proposal on improvements to mental health services has been complied at the request of Dr Wani Mena. It indicates that there is no properly functioning mental health inpatient ward. Regular incarceration of mentally ill people in Juba prison and the severely limited outpatient facilities .Very few people receive any treatment. Individuals who would recover given support and treatment remain a burden to their community and are non productive.

Staffing levels need to be comparable with international standards if an adequate service is to be provided.

Education of nurses and midwives and other staff.

Education for all groups of staff is required especially the following:
Infection control, observation of vital signs, ward management, leadership, staff development, professionalism, ethics, emergency and trauma care, and resuscitation for newborn babies.
Cleaning staff need proper equipment and training in how to clean properly.
Some education in these areas took place during the visit much more is required. There are some excellent senior nurses who with support would be able to teach and develop others. They also need experiences in a developed country to use as a benchmark.
The College of Nursing and Midwifery has competent staff with excellent motivation. When the group visited Juba, the contracts of employment of some of the teaching staff were for 1 year only which does not enhance stability of the College.
The facilities and equipment at the College are good and would be improved by the addition of more books and access to the intranet for students.
The students compare well with UK student nurses studying on diploma programmes in their enthusiasm and commitment. They have the ability to really take nursing and midwifery care forward. There is a need for clinical tutors who could help the students to apply theory to practice and make sense of the gap between optimum practice and the real situation on the wards.

There was an opportunity during the visit to teach and facilitate ward sisters and senior nurses. The attendance for each session was excellent and there is a need for more education for these groups.

Dr Baba asked for the names of key individuals who would benefit from advanced education and experiences in hospitals outside of Juba. Notable people are:

Sr Lona Jackson Sebit
Sr Anna Martin Gore
Sr Jemila Sake
Sr Rose Nunu Henry
Sr Grace Nimir

Some UK Universities offer sponsorship for Higher education Courses and visits to hospitals are possible, to experience international standards of care and treatment. To access scholarships staff from Juba will need to pass the IELTS examination with a minimum of 6.5 score. Juba has a local University where IELTS can be taken but fees for this may be prohibitive unless staff have financial assistance.
It should be noted that the recommendations in this report will need professional and managerial action and also to be responsible for the use and maintenance of any eqiuipment that is suggested, as well as developing appropriate procedures such as triage of patients and the undertaking of patient observation.

Sandie Paice MSc. PG Cert Health Education. PG Cert Coaching. RGN. RSCN. HV ( public health ) Accredited Leadership Facilitator. Nursing and Midwifery Practice & Education Advisor Juba Link. St Mary’s Hospital Newport Isle of Wight. UK


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