• Wesseh Koiblee, RN, Liberia

Most common procedures/Nursing Process performed wrongly in African health facility by Nurses

Written by: Wesseh Koiblee, RN, Liberia

Pictures by: Wesseh Koiblee, RN, Liberia

Physical Assessment, Wound Care, Specimen collection, Nursing documentation and Infection prevention and control measures are the most common procedures and nursing process performed wrongly by nurses in Africa. First and foremost, African government can and must do more to provide support for nurses and midwives. In health care systems, nursing care documentation is a significant and hefty gadget that ensures continuity of care and communication between health personnel for better patient outcomes. Knowledge, attitude and practice of nurses’ towards nursing care documentation affect the quality and coordination of patients’ care. Hence, this article aimed to assess knowledge, attitude, and practice and contributing factors towards nursing care documentation been the most common procedure performed wrongly among nurses in Africa/ Liberia. In many African Health facilities, Nurses do not provide wound care for patient but rather they leave it with the Nurse Aid. Wound care procedure is being carried out by the Nurse almost all of the time. The abandonment of this procedure poses serious health risk(wound break down) for the patient as many nurse aids lack the skill to perform such procedure as compare to the nurse. As we may know, wound care is one of the most critical procedure perform by nurses as patient had already been expose to multiple infections at home before seeking medication attention at the health facility. For this reason, Nurses should be more concern about caring for this type of patient and prevent complication.

During nursing school years, nurses were thought how to perform spacemen collection procedure. Even though there is lots of specimen procedure that are not thought during nursing school due to lack of said instrument/equipment in the lab. The student lab technician is the only one responsible to collect specimen in the lab during nursing school years, making many nurses in Africa not vastly knowledgeable on collecting specimen for patient during their career of practice.

The history of nursing care documentation started since the early days of Nightingale and defined as the record of nursing care that is planned and given to individual patients and clients by nurses. The quality and coordination of care depend on the communication between nurses with each other, with other members of the healthcare team for continuity of care about their patients. However, its value as an important source of reference in the health-care system is undermined because there is much confusion and lack of knowledge about the exact nature of quality nursing documentation.

Picture 1: Nurses Note on a Plan Sheet due to lack of printable form by hospital administration.

Nurses and midwives can make a significant impact in managing and preventing the leading causes of death. Nurses and midwives are the backbone of health systems globally. Of the world’s 43.5 million healthcare professionals, more than 20 million are nurses and midwives. They play a critical role. As quite often, they are the first and only healthcare professional’s people will see. Because nurses and midwives respond to the needs of people in all settings, they are critical to the achievement of global health goals. The World Health Organization (WHO) recognizes the vital role they play in promoting universal health coverage and sustainable development. According to WHO, the world needs 9 million more nurses and midwives to reach the global Sustainable Development Goal on health by 2030. It recommends a ratio of 83 nurses per 10,000 people. Infection prevention and control (IPC) is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers. It is grounded in infectious diseases, epidemiology, social science and health system strengthening. IPC occupies a unique position in the field of patient safety and quality universal health coverage since it is relevant to health workers and patients at every single health-care encounter. No country, no health-care facility, even within the most advanced and sophisticated health-care systems, can claim to be free of the problem of health care-associated infections. What more about Africa that have a struggling health system. Most definitely, we will have issue with IPC care than any other continent. The need for having IPC programmed nationally and at the facility level is clearly reinforced within the WHO 100 Core Health Indicators list. Most Common procedure performs wrongly by nurses in Africa: Even though there are so many challenges facing nurses and the health system in Africa, below are the most common nursing procedure perform wrongly by many nurses in Africa: Poor documentation (nurses note not legible, discharge note not comprehensive, procedure perform but not documented) Poor Infection Prevention and control (IPC) measure; Administering medication without gloves, establishing IV line without gloves, inserting Urine catheter without rightfully swapping, Inserting and removing NG Tube, not properly separating waste material (infection waste and no infection waste).

Firstly, we learn in nursing school that what has not been written was not done. In light of this statement, many report reflect that nurses in Africa does not perform many nursing procedures or if they did it was either perform wrongly. This is because; many nurses in Africa document very poorly after performing a procedure. Moreover, Poor documentation (nurses note not legible, discharge note not comprehensive, procedure perform but not documented) in patient record is due to so many reasons. For instance, in Liberia, many nurses do not document comprehensively narrative to clearly show the next person what and how a procedure was perform for the patient and the outcomes. They don’t document a comprehensive narrative for patient on admission and discharge; they don’t document head to toes assessment, they don’t document the specific discharge education /information provided to the patient. During one of my assessment and mentoring visit, I saw many nurses note that only read “Patient was discharge home stable and counseling was done”, which does not tell completely clearly show the picture of how this is stable to the next care provider. The record did not clearly state the type of counseling done and the data that make patient stable looking at the head to toes assessment and discharge vital signs and if patient should return to clinic if necessary. Many of the nurses when ask about their poor method of documenting, they attribute the behavior to the following: lack of time factors to document due to work overload, understaffed and other admit of lack of knowledge on proper documentation. Nevertheless, at some facility in Africa, there are a number of frameworks that is currently available to assist nursing documentation including narrative charting, problem orientated approaches, clinical pathways and focus notes. However, many nurses’ still experience barriers to maintaining accurate and legally prudent documentation like poor attitudes, lack of knowledge towards nursing documentation, time shortage and workload due to understaffed problem. This brings in-sufficient cooperation between health care team members and services that have a negative impact on nursing care documentation. Even though both paper based and electronic based nursing documentation have various principles including objectivity, specificity, clearing and consistency, comprehensive, respecting confidentiality and factuality, but nurses’ inadequate attitude and knowledge to document nursing care by using these principles makes nursing records usually of low quality with paper based documentation being the most common form of documentation (90%) used in Africa. Nursing care documentation is essential for early recognition of patients’ deteriorating condition followed by effective communication and response by members of the interdisciplinary care team leads to decreased hospital mortality. For this reason Nurses should document what they see, not what they think. Nurses bear a large burden in both managing and implementing the interdisciplinary team’s plan for documenting the care and progress towards goals since documentation is a working framework which provides a comprehensive account of care provided to a patient. Infection prevention and control (IPC), this is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers. It is grounded in infectious diseases, epidemiology, social science and health system strengthening. IPC occupies a unique position in the field of patient safety and quality universal health coverage since it is relevant to health workers and patients at every single health-care encounter. An effective IPC programmed is an essential component of any health service delivery; its implementation depends on the efficiency of the management and organization of the programmed at all levels of the health system. Haven’t said that, and base on my current and previous experience as a registered nurse and base on other report like the Performance Base Financing (PBF) under the process of care, I can safely say that Poor Infection Prevention and control (IPC) practices carry out by Nurses (Administering medication without gloves, establishing IV line, Urine catheter, and NG Tube, properly separating waste material) is the second commonly wrong procedure perform by nurses. Some of the contributing factor is as follow:

1. Carelessness/ Lazy fair altitude and etc 2. Lack of resources (no gloves, no washing soap, no hand sanitizer and E.T.C) 3. Knowledge deficit related Infection Prevention and Control measure 1. Carelessness; in the hospital and other health facility in Africa, there are many nurses who are just careless and don’t care about their own safety including the patient safety. Some of them think is time consuming while other think is not just necessary to observed IPC before during and after every procedure. Some nurses will administer injection to patient without wearing glove base of a reason that they are managing/saving resources. Many nurses with open Iv line without properly swabbing and wearing gloves, many do not wash their hands before and after every procedure or between patient. Many times there is no water in the washing hands bucket with forced. Many of the Nurses do not ensure to buy their own hand sanitizer knowing full well that the institution always run out of stock. Many of the Nurse under estimate washing hands in the hospital and just do it once awhile risking their own life and introducing new infection to patient because of this carelessness. One would also attribute these kinds of behavior to the health facility due to the lack of resources; even though some Nurses in Africa are doing everything possible to prevent patient from new infection by applying IPC rightfully, it is still a major challenge today affecting both the patient and the Nurse.

Picture 2 and 3: Poor IPC Measure (Environment: Latrine for patient on the labor and Delivery Ward Where Nurses Work in Africa)

2. Lack of resources: The limited supply medical material such as the Basic Personal Protective Equipments and Enhance Personal Protective Equipment (Glove, apron, face mask, face shield, head cover, chlorine, soap, hand sanitizer, shoe cover, booth, alcohol swap and etc). As regard to these challenges pose by the hospital administration, lot of Nurses perform many procedure without wearing the appropriate PPE thereby exposing them to many diseases like HIV, Hepatitis B&C, Ebola, Yellow Fever, COVID-19 and ETC. 3. Knowledge deficit; As years goes by, many Nurses keep getting in their old age while creating vacuum for new generations of nurses to come in and served. In so doing, there is a need to conduct regular IPC training for new employee and ensure that hospital administration provide IPC material at all time and empower the IPC focus person(IPC NURSES) to be effective in monitoring Nurses and assessed their IPC skills and conduct regular mentoring and coaching for those with weaknesses observed. Supervisor need to ensure that everyone is adhering to IPC protocol at all time most especially during patient care. If one can recalled during the Ebola outbreak, many Nurses lost their life including their loves one due to the poor practice of IPC during patient care. To reinforce these practices, WHO has set up a goal of good health and well-being for the entire worlds by 2030 and should be feasible according to the World Health Organization (WHO). Woefully, this might not be attained. Of course it is clear that it won’t be easy to address the shortage of healthcare professionals, especially in regions like Africa. It will take greater efforts to make nursing an attractive career, starting with appropriate training, then working conditions and pay, and retention of staff where they are most needed.

Picture 4 and 5: Places Nurses store their equipment in Africa.

With this been said, we encouraged the Ministry of Health and policy makers on the following: County Health Officer to include nursing care documentation as one of the orientation health package during employment. It is recommended that action be taken to boost the infection prevention and control (IPC) nursing workforce in Africa, especially during the COVID-19 pandemic. It is also recommended that ministry of health should try to consider nurses’ benefits. It should adjust training on nursing care documentation standard and give direction for health center and Hospital administrative department to encourage nurses to do their activities and document what they provide timely with robust supervision from their direct supervisor. Government Nursing Division should conduct a regular (quarterly) In-service Training, shoulder to shoulder Mentorship and coaching on proper documentation. It is recommended to recruit nurses to adequately staff every facility base on census and catchment population taking into consideration Full Time Equivalent (FTE) and the Nursing Hour per Patient Day (NHPPD) to enable efficiency and reduce burn out for staff. Hospital should have champion who will create a system to follow, monitor, mentor and coach staffs how they implement nursing care documentation and give feedback for those staffs that faces problem. Accountability should be highly considered which is not currently. An assessment on nurses’ knowledge, attitude and practice of nursing care documentation should be conducted quarterly and finding should be submitted to relevant authority for further solution. To climax, I recommend that government and private institution read this article and follow the recommendation as stated to prevent documentation error and promote patient and staff safety with strategy put in place to closely monitor the used of IPC by nurses during every procedure. Let me acknowledge the administration of Translate Nursing & Liberian Care International for affording me the opportunity to share my perspective with the international world. Identifying problem and finding solution to issues that affect health care: Preventing behavior that undermined patient safety and nurse’s safety has been one of my goals since I was a child. I therefore believe that with the help of Translate Nursing and LiberianCare International, my dream will be achieve.

Please email me if you have any question.

Wesseh Koiblee, RN, Liberia

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