As the world grapples with the COVID-19 pandemic, healthcare professionals are at the crux of it all and key to the resolution of the emergency. They have been hailed “heroes” for this very reason, and across Europe and the rest of the world, neighbourhoods and cities have been applauding their heroism.
Healthcare professionals, and this includes nurses and midwives, are on the front line of the battle with COVID-19 pandemic. And although this year’s World Health Day theme was conceived without a thought to the threat of a pandemic, we even celebrate them more at this crucial time!
On April 7 every year the world celebrates World Health Day, a day set aside to create awareness of a specific health theme to highlight a priority area of concern for the World Health Organisation.
This year’s theme, the International Year of the Nurse and the Midwife, focuses more on the vital role played by this cadre of staff within healthcare systems. No doubt this will resonate well with a lot of us in this region of the world with under-resourced health systems. Nurses and midwives play a vital role in our healthcare system, oftentimes being the only available workforce within a given health facility in a community.
The price of heroism
In a country such as Nigeria where doctors are in limited numbers and mainly function at the expert level of human resources for health; nurses and midwives provide the day to daycare, are more in contact with patients and are likely to be more at risk during pandemics.
At about mid-March, Nursing Times reported that the International Council of Nurses was getting reports from its member associations of increasing deaths of nurses who have contracted COVID-19. In Italy, so far, 10 per cent of health care workers (HCWs), totaling over 6,000, have been infected in their fight against this virus, most of them doctors and nurses. In Spain, over 100 doctors and nurses have died from the virus, with a similar increasing death toll of HCWs in the US, UK, France, etc. In one particularly heartbreaking death of a nurse, Kelly had texted his sister “I’m okay. Don’t tell Mom and Dad. They’ll worry,” while on ventilator care at the hospital where he worked.
But amidst this rising death rate of HCWs across Europe and America is a little ray of hope from Germany, with so far the lowest death rate from the disease, even as it is seeing the same age category of people infected. It has in part been attributed by Epidemiologists to Germany’s robust public health care system, with a 40,000 ICU bed capacity and a highly larger number of nurses to patient ratio. In fact, Germany has the highest number of this at a significant 13.8:1,000.
While in Nigeria, with a total estimate of 128,918 registered nurses and 90,489 midwives, we have on average one nurse to 1000 patients in hospitals, but with this number more likely to be concentrated in the urban areas due to reasons we are perhaps more familiar with.
The global outlook in terms of nurses/patients ratio is also nothing to cheer. The standard recommendation, for instance, is that in critical care units such as ICUs (intensive care units) the ratio is to be 1:1 for the sickest patients or 1:2 or 1:3 for patients who are acutely ill but stable. On general care units, the nurse to patient ratio is set higher, for example, 1:5 or 1:8 depending on the type of unit and the needs of the patient(s).
In our situation, this is a rather worrisome statistics that underscores the dearth of nurses/midwives in the country. In fact, estimates have put the country as running on a 32 per cent average deficit of this category of HCWs.
How is this fight looking like for us as our nurses and midwives are the only line of defence most of our communities would have during this period? We examine the crucial role nurses and midwives have been playing in infection control at our primary care units, especially with the endemicity of Lassa fever, and the emerging COVID-19 pandemic which has to date over 200 persons infected in Nigeria, more than a million cases worldwide and projected to rise further. With an increased rate, there will be more strain on health systems and human resources, especially nurses and midwives in Africa, along with them.
A nurse’s perspective
Mindful of the issue, Premium Times had collated a number of voices of nurses and midwives currently on the field at COVID-19 isolation centres across the country. In what seems like a cry of dissatisfaction with the working tools, and staff welfare, nurses/midwives at our frontline have expressed their opinion on the lack of appropriate gear and pre-field deployment practice or simulation of infection control measures.
But the risks from COVID-19 seem to be already apparent from the news of rising cases among nurses and other healthcare workers. According to the United Nations, nurses are working in under-protected settings in many parts of the world. Personal Protective Equipment (PPE), and in particular the much needed N95 face masks are in severe shortages. Nurses at Jacobi Medical Center in the Bronx, New York had staged a protest, for instance, demanding PPE. Watching and reading stories of shortages in Europe makes us wonder what number we have and plans of bridging the gap if/when shortages start happening as we are seeing elsewhere.
In the mentioned report by Premium Times, the chairperson of the association of nurses and midwives, University College Hospital, Ibadan had mentioned the need for “. . . nurses attending to those tested positive must be trained”, perhaps pointing to the fact that infection prevention and control strategies are not part of our focus at primary levels of care.
Avoiding HCW fatalities
All evidence and history also point to the fact that nurses are always disproportionately affected in the face of an outbreak, epidemic or pandemic. Take the SARS epidemic, for example, healthcare workers, which primarily include nurses, accounted for one-fifth of the disease incidence rate.
However, recent studies on infection control among HCWs in Nigeria, have consistently emphasised the importance of knowledge, skills and practice behaviour of basic infectious disease control principles for survival. This is because apart from providing the needed care for sick patients at contact points, there is an increasing report of HCWs contracting infections for which they are treating patients. This is an important issue to look at since these usually lead to the death of such HCWs themselves, and they become points at which such infections re-enter the community, especially in a circumstance of an epidemic.
In one study that looked at the effect of training on infection control among nurses in selected Teaching Hospitals in Nigeria, the results showed that most nurses became more experienced at infection control as they stayed more on the job, with occasional training adding to this experience. Furthermore, training tended to boost this vital skill set significantly.
Similar findings were observed in another study that looked at Infection Control and Practice of Standard Precautions Among Healthcare Workers in Northern Nigeria. Here although a majority of the HCWs reported good knowledge of universal precaution and infection control, recognise handwashing technique, sterilisation process, and various equipment used for personal protection, and appropriate handling of waste as essential technique of universal precautions for infection control, there was an almost all percentage of workers having no knowledge of vital policy guidelines such as the National Injection Safety Policy and Policy on Sharps Disposal. A majority of the sampled HCWs had not also received any training on infection control in the last two years.
Also during the Lassa fever (LF) outbreak of 2018, research looking at infection control among HCWs at the designated treatment centre for LF in Ebonyi State, it was found that those with better knowledge on infection prevention and control were those directly involved in the responsible units and had mostly spent an average of 15 years in the facility.
On the whole then, what this deficit in infection prevention and control readiness, coupled with the available number of nurses/midwives in our communities, tells is the dire situation we are perhaps running into.
A Gap to be filled?
Although several healthcare programmes are implemented across the country with a focus on infection control, these efforts seem to have been single, and without a focus on epidemic awareness and preparedness at our basic levels of care. The HIV epidemic saw the development of the Infection Prevention and Control Manual, focusing on safe injection for Health Workers in 2015. But this may have only been put in place among nurses/midwives working with an HIV/AIDS programme.
One study in Northern Nigeria identified the need for formal and periodic refresher training. We may have therefore been missing an important part of being ready for a disease outbreak; having trained our nurses/midwives poorly on infection control and disease surveillance. As this outbreak may show here too, it is not all about the available equipment, PPEs when used incorrectly do not have many advantages and may even pose greater harm.
We consequently call for the protection of these heroes with in-service training that is extensive and supported by job aids pasted on facility walls, to save nurses/midwives lives who are on the frontline of the pandemic.