Afew years ago, Jovia, a nurse in Kiziguro in the Eastern Province got injured while attending to an HIV-positive patient. During one of her daily routines, a syringe that had been used on the patient slipped from her hand only to pierce into her skin. With adequate medical knowledge, immediate prophylaxis measures were taken and she went on ARV treatment for 28 days.
During the course of her treatment, Jovia started developing side effects. At first, her sight became blurred and almost became blind after three months. On carrying out further medical tests, it was discovered that she had got an infection from cytomegalovirus, a herpes virus that causes serious effects and probably it was responsible for damaging her eyesight.
Desperate to get a cure, the young nurse moved from one health facility to another. Hospitals such as Kabgayi District Hospital also got to know of her case. Fortunately, Jovia did not contract HIV/AIDS, but her life now survives on continuous assistance. In fact, the poor eyesight almost landed her in an accident when she tried to cross the road by her herself once.
As Rwanda joined the rest of the world to mark the International Nurses and Midwives Day recently, the plight of both nurses and midwives within health centres featured prominently among the issues that require improvement all over the world. Besides accidents, some nurses have experienced abuses from their superiors, colleagues and patients while in the line of duty. Jovia’s case serves as one of such incidences, but it is just a tip of the iceberg of the bulk of challenges that nurses and midwives face.
Rwanda Nurses and Midwives Union President, Andre Gitembagara, explains that such incidences are discouraging others who want to become midwives or nurses.
With a perception that several risks come while working as a nurse or a midwife, absence of proper protection puts nurses at risk of contracting diseases such as tuberculosis and HIV, among others, says Gitembagara.
“But that’s not all; some who are already enrolled are even running away from the profession, joining the business sector because they feel it is more profitable. Imagine being harmed in a situation where you are trying to help others,” he explains.
Last year alone, 16 nurses contracted TB during their work, one acquiring multi-resistant drug tuberculosis (MDTR).
“The cases were different but those are indicative of the plight that some of us face during our work. You handle a patient who is very sick but at the end of the day they treat you like a house boy,” says a nurse at Kibagabaga Hospital.
A summation of such challenges only widens the shortage gap of midwives and nurses that currently stands at
45 per cent in health centers and 20 per cent in district hospitals.
Enrollment of nurses and education levels
Despite a multitude of challenges, there has been tremendous progress in this sector. Currently 10,000 nurses and midwives are registered compared to only 400 that existed before 1995. Of these, about 1,200 are midwives according to statistics from the Rwanda Nurses and Midwives Union.
“Ordinarily, each woman in a health facility needs at least two nurses and that would be a general nurse and a midwife but the figures suggest that this demand only calls for improvement,” adds Gitembagara.
While majority serve as low grade or enrolled nurses, the Ministry of Health requires all nurses and midwives to upgrade their levels of education from enrolled nurses (A2) to (A1) or better still hold qualifications such as diplomas and degrees.
This, according to Josephine Murekezi, the president of the Rwanda Association of Midwives, is stifling the progress of bridging the gap of these healthcare providers within the facilities.
“There is shortage and it is because the people we have cannot cover all the maternity wards. Again, the demand of midwives is increasing despite the fact that some who qualify are not employed,” says Murekezi.
Murekezi, who is a trained midwife, further points out that the ministry prohibits A2 nurses or midwives from carrying out deliveries.
“It is a complex situation. Sometimes they could be the nurses on site yet you don’t want them to carry out deliveries. It is also not necessarily true that they do not have the proper experience. Unfortunately women could deliver with unqualified people if such issues remain unaddressed,” she explains, adding that: “The remuneration of nurses and midwives which is streamlined worsens matters. Some nurses are not paid commensurate to their levels of education. Many with bachelor’s degrees receive the same pay as diploma holders.”
During celebrations to mark the International Day of the Midwife, recently, Gitembagara also noted that there was a gap of 45 per cent in health centres and 20 per cent in district hospitals of the recommended workforce.
‘‘There are 1,238 registered midwives in the country compared to the required 4,000 midwives,” he said.
Issues of malpractices
Other stakeholders in the health sector also feel that both regulation and remuneration of nurses should address the malpractices within the sector.
Figures from Rwanda Nurses and Midwives Union indicate that almost 200 nurses and midwives in Rusizi District were operating without licences last year.
Such findings supplement the move by health bodies that recently saw the Ministry of Health suspend at least seven nurses from different areas.
Nathan Mugume, the head of communications at the Rwanda Biomedical Centre and the Ministry of Health, reiterated that after conducting investigations earlier this year, the suspension followed as an intervention to improve health services.
“Investigations are ongoing but most of these facilities were closed because of acting contrary to professional standards through malpractices,” Mugume told The New Times earlier.
Other statistics from Rwanda Nurses and Midwives Union revealed that 40 cases of nurses involved in malpractices were recorded last year alone.
Gitembagara further points out that measures to iron out such malpractices are implemented with support from the ministry.
“When it comes to misconduct, disciplinary action is two-sided and may be professional or penal. The ministry takes measures but if the misconduct is to do with the system then the council takes over since its duty is to safeguard the patients,” he elaborates.
The 5 Steps of the Nursing Process
The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps.
The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient’s psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative phase.
The diagnosing phase involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include an actual description of the problem (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient’s readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardized terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning.
The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up. Implementation can take place over the course of hours, days, weeks, or even months.
Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine of the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient’s condition improved, patient’s condition stabilized, and patient’s condition deteriorated, died, or discharged. In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.
All nurses must be familiar with the steps of the nursing process. If you’re planning on studying to become a nurse, be prepared to use these phases everyday in your new career.