Building skills of Nursing Professionals in newborn care for health facilities in India
Dr Manju Vatsa1,2 , Dr Marsha Yeo Campbell3 , Dr Ashok Deorari1
1Department of Pediatrics, 2College of Nursing, All India Institute of Medical Sciences, New Delhi, India, 3Dalhousie University, Halifax, Canada.
With increasing births at health care facilities the demand for skilled healthcare professionals for normal and sick newborns has increased. The creation of Special Care Newborn units (SCNU’s) and 24 x 7 birthing units under the National Rural Health Mission (NRHM) is a laudable effort by the Government of India to improve the care of mothers and babies. These local free facilities have opened care, even for the most poor, and provide incentive for families to seek institutional births. 1,2
Nurses play a pivotal and varied role in these healthcare facilities that encompass prenatal education, labor and delivery, and ongoing newborn care. Most notably nurses provide skilled attendance during birth, perform 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, their role is especially critical at district, sub-district areas, and villages. Although these nurses generally have a collaborating physician in a regional centre often greater that an hour away, they generally practice alone in these local care facilities and SCNU’s, conducting newborn deliveries and treating at risk and sick brought from the community. Despite these expectations, strategies for the educational preparation and resources for ongoing learning is varied and often limited.
In view of such an important role being shouldered by nurses in health care facilities and SCNU’s, a structured evaluation of the identification of barriers and facilitators for education of nurses in the care of at risk and newborn babies in India was conducted by an Indo-Canadian team of physicians and nurses. This involved conducting twelve Focus Group Discussions (FGD) 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). Most of the female participants were nurses (82/97),10 were Auxillary Nurse Midwives (ANM’s), 3 were physicians and 2 self-identified as other (administrator or accredited social health activist). The participants identified several areas of learning needs including resuscitation, immediate stabilization of sick newborns, ongoing clinical care, and the care and maintenance of equipment. Additionally, the majority of the nurses voiced the need for evidence based and consistent orientation to newborn care as this was not a core competency in their general nursing education nor a consistent part of their unit or facility based orientation.Detailed information is provided in a full report at http://www.newbornwhocc.org/pdf/APW-WHO-SEARO-Shastri-Report.pdf
Most notably, priority should be given to the following identified challenges.
1. Since most of the local 24 x 7 health facilities are solely managed by ANM’s and nurses, with support from doctors from regional centers, keeping resuscitation knowledge and skills updated for ANM’s and nurses is a herculean task. It is essential that consistent training is provided that include components that address, skill acquisition, consolidation of learning and practical hands on practice and utilization. The use of flip charts in local language and demonstration models, which are readily available at site for practice, will go a long way.
2.Due to high turnover and lack of adequate exposure in pre service education of essential & sick newborn care management, the nurses desired having a uniform, structured competency based training package in SCNU’s.
3. Opportunities, linked to incentives like credit hours by Indian Nursing Council (INC), need to be provided while in service to undergo continuing education on regular basis.
4.For having a sustainable impact, the current pre service education program for nurses needs to be augmented by strengthening the nursing curriculum related to the care of at-risk and sick newborns.
5. Given the ongoing scarcity of phyicians to man 24×7 units in villages, policy makers and administrators should consider the exploration of the creation of a cadre of neonatal nurse practitioners to fill this gap and ensure optimal care for newborns in these facilities.
6. Strategies to raise the importance of the nursing profession and role that nurse play in improving newborn health, including attention to working conditions and manpower issues will directly affect desired outcomes.
The findings of Indo-Canadian Shastri project supported by a matching grant from the WHO SEARO, New Delhi, were shared at a Stake Holders meeting attended by majority of 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, academics, 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. For further reading read report : http://www.newbornwhocc.org/pdf/APW-WHO-SEARO-Shastri-Report.pdf
References
1. Lim S.S, L. Dandona, et al. (2010). India’s Janani Suraksha Yojana, conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet 375 (9730):2009-2023.
2. Public Health Foundation of India (PHFI) policy brief on Equipment and manpower for SCNU 2011.