8 Oct, 10 | by BMJ
It’s 1:00 am. My colleague and I have just returned from a surprise visit to the hospital. Three times a month we do spot checks on the wards; periodically we check during the early or late shifts and occasionally during the night and weekend shifts. The reason for these checks is that the Welbodi Partnership set up a performance-based incentive scheme a couple of months ago to monitor nursing care at the hospital with the aim of improving staff performance and ultimately reducing child mortality.
Unfortunately nursing care at Ola During Children’s Hospital has been suboptimal for a few years. This is due to various reasons, one of which is that for years salaries were low, and nurses were forced to work elsewhere, abandoning their posts at the Children’s Hospital. This caused a dramatic fall in nursing standards. Also, high medical fees meant that patient wards were half-full and patients often could not afford proper treatment and mortality rates were high. This was demoralizing and led to even more nurses not showing up to work. Lack of equipment and supplies worsened the matter.
In April 2010 the free health care initiative was launched for patients under-5 years. This led to more patient admissions and a heavier workload for the nurses. For some, this made it difficult to stay motivated again.
Thankfully, a few months ago the government increased the salaries substantially, which led to an influx of nursing staff. For some nurses that was enough of a motivator to come to work when scheduled and perform well. Sadly for others, this was not enough of a motivation.
The set up of the scheme is to do spot checks using set criteria to monitor the level of care given. The criteria include checking if every bed has a mosquito net, if every patient has a sheet or “lappa” to lie on, and if soap and water are available. We also check if all scheduled staff are present and in uniform, and if equipment is clean and well maintained. Sharps must be disposed of properly. We look to see if patient’s vital signs have been checked, if medication has been given accurately, if the handover book is filled out and the ward is clean and the nurses’ station tidy. The criteria are modified as time goes on and are often linked to what the nurses have been taught in a workshop.
Although the scheme sounds simple, it is actually quite complicated. It looks at a ward’s performance, not an individual’s performance. So, if a colleague does not show up to work, the others on the ward are penalized. If a colleague has not documented medication properly, points are deducted for the ward and everyone is affected. It does not sound fair, but the idea behind it is that nursing care should be based on teamwork. When one person falls, everyone falls. Unfortunately we are not able to monitor each nurse’s individual performance because that would be a full time job. So, we look at the performance of the ward as a team. If one shift functions poorly, then the other two shifts will be affected.
Another issue is that the same scoring method is used on every ward, but every ward has a different workload. Obviously 3 nurses in the observation unit or measles ward will be able to handle their work load of 5 – 10 patients much better than 2 nurses in a general ward with 40 – 50 patients, or 4 nurses in an ICU with 40 patients. Fortunately Welbodi encourages local ownership and makes sure to engage matron’s office in every check. This allows Welbodi and the matron’s office to discuss issues such as the number of nurses posted to each ward and so on. It also empowers matron’s office to enforce rules and the nurse’s code of conduct.
The actual checks are a bit of an adventure, especially on the weekend or in the night. Sometimes I am a little nervous as I don’t know what I will come across. Fortunately tonight was okay. Some things were not so good and definitely need to be improved, but thankfully there were also areas that had improved. Most of the staff was present which was a welcome change from a few months ago. The main issue now is proper administration and documentation of medication but I am convinced that with more training, mentoring, and feedback this too can improve. As I said before, it’s not simple. Constant monitoring and evaluation of the program is crucial to make sure the scheme still works towards improving nursing care. It needs to be a scheme that continues to encourage the nurses and not discourage them. Their job is not easy but it is so desperately needed and we need to help them find a way to regain a passion for what they do- helping the children in Sierra Leone.
Sandra Lako is a doctor from the Netherlands who previously spent four and a half years in Sierra Leone setting up and managing a pediatric outpatient clinic with an organisation called Mercy Ships. After a year at home, she returned to Sierra Leone to volunteer as medical coordinator with the Welbodi Partnership, a UK based charity supporting the only government-run children’s hospital in a country where 1 in 5 children do not reach the age of five.