Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

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Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

The end of the short course route to become a SA paramedic

For years there have been rumors about the end of short course training for paramedics in South Africa.  It became real on 27 January 2017 when the Department of Health published a regulation pertaining to the qualifications for registration of the short courses. 

A brief background to those unfamiliar with the system:  Until now there has been a dual system to become a paramedic.  Taking the short course route meant completing a 4-6 week course in order to qualify as a Basic Ambulance Assistant (BAA). The BAA can do the basics including (but not limited to) the administration of oxygen and splinting of fractures.  For a long time (possibly still?) BAA’s was the backbone of the Emergency Medical Services (EMS).  Especially in the urban areas where there is a high density of hospitals, the BAA is valuable because they can perform basic care, load the patient and rapidly proceed to the closest facility.  This implies fast access to definitive care.  Career-wise to advance the BAA had to complete working full-time for 6 months or 1000 hours as prerequisite to apply for the next course. If successful, the BAA could then do the Ambulance Emergency Assistant (AEA) course.  The AEA can perform skills including nebulization and commencing IV therapy.  Again after 1000 hours or 6 months of full-time working, they can apply to do the 9 month advanced life support paramedic course.  This course has limited space and the entry exams are tough; thus AEA’s often have to work for a number of years and gain experience prior to doing the course.  This pathway to become an Advanced Life Support Paramedic is now being scrapped in favor of a 4 year degree program at selected UT’s.

In many ways this agenda has been driven by a desire to professionalize and create the capacity for research within the field.  Still there is an eerie sense of dèjá vu; the impact on training is similar to what happened to nursing not so long ago.  During the late 90’s in an attempt to restructure nursing, various colleges were shut down, shorter nursing courses were suspended, the university curriculums were adapted and the intake of nursing students at these institutions reduced.  Shortly thereafter community service for new nursing graduates became compulsory and to become a nurse meant 5 years of studying.  Fast forward about 20 years, and South Africa has an estimated shortage of 45 000 nurses, with only 3 500 new nurses are trained per year.  According to Nursing Council statistics 48% of Professional Nurses are above the age of 50 with 25% of nurses under the age of 40; of these only 5% are under the age of 30.  The shortage of nurses is dire and will continue for the foreseeable future, especially when the 48% above 50 start retiring in the next decade. 

The shortage gave rise to contract nursing, also known as ‘moonlighting’ where nurses work overtime shifts or only work as agency nurses.  Moonlighting caused (well-described) drastic consequences on the quality of nursing care in South Africa.  Furthermore it attributes nurse burnout.  Sadly it also costs the hospitals more money to buy-in agency staff, it increases the load on the nurse managers to process hours, plan staffing, negotiate and book agency staff. 

There are a few lessons to learn from the above.  Sadly though, paramedicine seems to be on the same trajectory. Other concerns include

1)      University qualified paramedics = higher salary expectations = higher budgetary demand

Remunerating a workforce that consists of degree paramedics will be at a far higher cost than paying different levels of short-course practitioners.  In a country where the health system is struggling with budgetary constraints exists I’m not sure whether the provincial health services would be able to accommodate increased salary budget demands without compensating other vital aspects such as vehicle maintenance, equipment or stocks.

2)      Related to the above.  The cost to train a degree paramedic

The cost per student is higher at a university than with in-service training. The duration of the courses are longer, meaning that any investment will only yield results in 4-5 years.  How can this be seen as cost-effective in a country with budgetary constraints, a growing burden of disease and ever-increasing demand? 

3)      Brain drain

It is not a new problem that newly qualified paramedic graduate leave the country in hordes.  They earn better salaries in Qatar, the UK and as contractors for the oil and gas industry. Thus the back bone of the provincial services has remained short course paramedics.  In the Western Cape the vacancy rate for paramedics in the public sector is 7.5% (2015/16 DOH report).  This is the highest across all healthcare professionals in the public sector; it is even higher than the nursing vacancy.  Taking away the short courses, spending all the money to train graduates and then have them leave the country doesn’t seem to solve the pressing issue of high vacancy rates.  The vacancy rate might already imply a paramedic shortage. 

4)      Loss of tacit knowledge and experienced practitioners 

Over the past decade the career progression for paramedics that came through the ranks by doing the short-courses has become more and more limited. Often despite their years of experience, they cannot apply for management positions; they earn less that their newly qualified inexperienced colleagues.  Because they know the system they often end up carrying newer qualified degree paramedics.  Over the years with the constant threat of the end of short-course training, and the rise of more and more degree paramedics, these practitioners have become disgruntled and unhappy.  Now that their qualification is officially extinct, why should they stick around in the industry? And can South Africa really afford to lose their knowledge and experience?

5)      Increased barriers to access emergency care 

I’ve been part of the Hout Bay Volunteer Ambulance Service (HBVEMS) since 2004, a community-driven ambulance service that predominantly functions with short course practitioners.  With no more short courses, the growth and sustainability of services such as HBVEMS are stunted.  The volunteer pool will shrink until there is no service left.  This is true for volunteer services across the country and it creates a gap in service delivery and access to essential emergency care.

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6)      Impact on fire services 

In Hout Bay and other areas, the fire services fill an important gap as first responders.  Often patients are taken to fire stations where care is rendered whilst waiting for an ambulance.  This is done by fire fighters that have completed the short courses.  As rendering emergency care is not their primary duty is seems nonsensical for them to do a 4 year degree.  Again the impact of fire fighters no longer being qualified to render basic care will be felt by the community.

7)      Paramedicine = exclusivity

A degree program has higher entry requirements than skills based programs, helping the professionalization of the field.  I fail to see how the professionalization and more elite paramedical qualification contributes to better serving the need of our country’s growing population.  Would the same money to train degree paramedics, not be more useful if used to purchase more ambulances?   Is scrapping short-courses really in-line with the needs of the population of South Africa?  Not to mention that there’s been studies questioning whether having higher qualified paramedics on scene actually equals better care, as they are more likely to spend longer time on scene performing advanced interventions that is not always required.  In the end one of a paramedic’s core functions is to stabilize and transport to definitive care. 

The key arguments for discontinuing short courses are that short courses do not comply with the National Qualification Framework Act.  And in order to professionalize paramedicine a degree program is required.  It has also been stated that the Health Professionals Council of South Africa has to protect the public by ensuring the registration of appropriately qualified emergency care providers who has the skills to practice their profession safely. 

“We learn to do something by doing it. There is no other way.” – John Holt

I completely agree that there should be a degree program that helps advance the field, promote research and education.  However in the end, a good paramedic is someone that can apply their skills.  Paramedicine is a skills-based function and whether having a degree equals being more skilled to perform practical interventions are questionable.  I disagree that the ‘professionalization’ of paramedicine at the expense of short-course programs is the best way forward.  Especially in a country that has a growing population, quadruple burden of disease and inequality in accessing care.  In fact to solve some of the problems that we face in emergency care, maybe we should rather follow one of the ideals of the Gates foundation:  “The ideal is creating a skills-based credential that is well trusted and well understood enough that employers view it as a true alternative to a degree” (Bill Gates 2013)

Communication: Semmelweis vs Florence Nightingale

A comparison of two intriguing nineteenth century change agents.

The lady with the lamp: Florence Nightingale, founder of modern nursing, demonstrated the effectiveness of hospital design and administration.

The saviour of mothers: Ignaz Semmelweis, demonstrated statistically that puerperal fever could be reduced by hand washing and implemented hand hygiene at the point of care.

The one was acclaimed during her lifetime; the other died an outcast of medical society in a mental institution at the age of 47.

Similarities

Semmelweis (DOB 1818) and Nightingale (DOB 1820) lived in the same era of health care development.

Both had novel ideas that challenged the existing status quo.

Both used statistics to demonstrate their findings (not commonly used at the time).

They made their world-changing discoveries roughly at the same time (1847 and 1854)

Their discoveries were in the same branch of medicine: spread of disease.

Neither one was completely right.  Semmelweis failed to realize that puerperal fever is an airborne and contact disease.  Nightingale lacked “scientific” insight into the spread of disease.

Brief backgrounds

Nightingale was a lady from the upper class in the Victorian era of British history; women had no legal rights and a Victorian lady’s world was strictly confined to home and family.  Florence’s father held progressive views on the education of women and she was well-educated.  However it remained a radical concept that a privileged lady would want to have a career, especially as a nurse!  Nursing was considered a job for untrained, uneducated women with no other prospects and of poor social standing.

Semmelweis was born in Hungary, the 5th child out of ten in an affluent family from German ascent. He was a physician and worked in a large training hospital in Vienna.  There must’ve been a degree of underlying tension for the Hungarian physician working in Austria due to the European political framework of the time.

How did they communicate their findings?

Florence Nightingale consistently communicated and consulted widely, publishing approximately 200 books and 12 000 letters.   Nightingale was strategic in her allegiances.  She attracted talented and powerful collaborators, connecting with a variety of influential people.  She networked across boundaries, even internationally.  Her collaborative efforts with Sidney Herbert are well-known and demonstrate her ability to influence the right people.  Sidney Herbert carried weight in social circles, he had an influential position and enough access to the Queen to make promise Florence prior to Crimea “unlimited power of drawing on the government for whatever you think requisite for the success of your mission.”

Semmelweis was a reluctant communicator and words used to describe his style includes dogmatic, arrogant and ego-driven.  He displayed a tendency to describe his peers using words such as irresponsible murderers, criminals, adversaries and partners in the massacre.

With the implementation of Semmelweis’s hand washing at point of care idea the mortality rate dropped from 18 – 1%.  For reasons unknown he refused to communicate his reasoning and findings to the learned circles. Only fourteen years after the experiments and after he has left Vienna did he publish a book.  The book was poorly received as it was reportedly poorly written and hard to follow.  Semmelweis responded to the reviews by writing public letters, which did little to win support within the scientific community. He died four years after the publication in a mental institution.  His admission to a mental institution is filled with myth.  He’s reasoning was only accepted 20 years after his death with the further discoveries on the germ theory of disease (Louis Pasteur) and antiseptic techniques (Joseph Lister).

Could Semmelweis have had a greater impact if he could communicate differently? I think yes…

The power to influence

Obtain buy in.  Most of us view ourselves as individuals making independent decisions based on facts, however the behaviour of similar others (our peers) have an influence on our decisions, not to mention our preconceived notions.  When the way that we interpret facts are questioned it threatens our truth and the way we see the world resulting in self-defensive behaviour. The gentlemen doctors in the nineteenth century did not believe that their hands carried germs.  For fourteen years Semmelweis declined to share why he was so forcefully challenging this status quo and insulting his peers.  Semmelweis behaviour made it easier for his peers to shun him than to challenge their own beliefs and buy into his message.

Don’t force your opinion (even if it’s right). Semmelweis felt passionately about his message and his statistics proved that he was “right”.  So he forced his message and when it didn’t work, instead of reviewing and adjusting, he raised the tone, making it more aggressive.  He kept pushing, refusing to consider other’s inputs and views.  It’s not only about the facts; it’s also how we go about communicating and adapting our message that counts.

Use a consistent message in different ways. Nightingale used various ways to communicate the same message.  She wrote letters, books, presented statistics, comparing English and French outcomes and collaborated widely.  She wrote in simple English and innovated difficult statistics into easier visuals ensuring that her message was clearly articulated and understood.

Apply some charm. In addition to our bias, we are more likely to follow the lead of people that we like.  This makes charisma an important leadership and change agent trait. Charismatic people are skilled communicators communicating using just the right amount of emotional appeal to lend credibility to their message.

Nightingale’s background prepared her to be an intuitive and skilful communicator.  She innovated to clarify her message (statistically); she used her influential collaborators and she was persistently persuasive. The power to influence people and get them to work with you or even on your behalf is and advanced form of social interaction. I think Nightingale was a clever strategist and communicated with intent.

Summary

There is a Chinese proverb that states that he who threads softly goes far.

Communicating is a skill. When challenging the status quo we need to be intentional, adapting our personal style yet remaining true to ourselves and our truth.

Footnote:  Semmelweiss was able to make his deductions after comparing a nurse driven clinic (low mortality rates) and a doctor driven clinic (high mortality rates), Nightingale made her deductions from nursing experience.  Both cases illustrate the important role of nurses in improving and advancing health care.

It’s more complex than it seems….19 babies received the wrong vaccinations

A week ago there was an incident at one of the private hospitals.  Nineteen new-born babies received the incorrect BCG vaccination and are now at risk for contracting Tuberculosis and suffering other side effects.   According to the media reports, the vaccine was confused with another drug used for a different patient population (adult and new-born) with different indications. But vials are similar in appearance.

No doubt the parents are furious and the media has a duty to report and allow for public comment.  I keep telling myself not to read the comments alas I still read it.  The readers has crucified the nursing staff involved and are blaming the lazy, stupid, can’t read, how-hard-can-it-be-to-do-your-job nurses.   Stupid nurse, fire the nurse.  End of story.  Problem solved.

Errors and failures in complex systems such as hospitals are not that simple.  It is not linear with a direct and clear relationship between cause and effect.  And neither are the interactions between the various functions within the system linear either.   In complex systems there is no single most “fundamental” reason for an error.  There is an interaction of several causal factors originating from various places within the system.  The inquisitive investigator will find patterns between apparently unrelated incidents prior to this incident.

The impact of a blame culture or over simplified cause and effect investigation results in system failures being “blamed” on the last “link” prior to the incident.  This last link is typically the doctor or nurse involved in patient care.

Possible contributing factors to the vaccination error:

  • The drug manufacturers.  There has been an increasing push on manufacturers to distinguish medication and provide visual cues on ampoules as warning prompts.  For instance the difference between medication manufactured for adult, paediatric and neonatal should be visible by either colour or tag.
  • The pharmacist that dispensed the drug had a duty to check and label it.  The question should be asked that if an adult drug ended up in a new-born unit, was there a dispensing error?
  • Responsible person receiving and unpacking the medication in the unit.  This person has to check medication received against requested medication.  The role is performed by an administrator with no nursing background.  If the packaging was familiar and the name similar, they would miss the error or assumed it is a generic.
  • The first nurse to administer vaccination using the vial.  There is policies dictating that nurses perform the 5R’of medication administration to ensure that it’s the right drug, right dosage, right route for the right patient, at the right time.  Was this done, and could the nurse complete the check without interruption?
  • Normalizing deviance.  If the same constraints are experienced on a regular basis it is accepted as normal.  When it’s accepted as a “new” norm it creates an environment where failure or error is inevitable.  Nursing shortages has become normal; this has an impact on safe medication administration practises as well as the frequency of interruptions during this risky time.  This normalizing deviance results in medication error becoming inevitable; the question is simply when it is going to occur, not if.
  • Latent factors includes management decisions, staffing levels, general policy and procedure, design of the unit, the pharmacy and the hospital, staff related factors such as perceived time pressure to perform tasks, fatigue, amount of recent shifts worked, was this an overtime shift, how many hours since the last uninterrupted break.  Level of experience of the nurse, pharmacist, ward administrator.  These latent factors can be dormant in a complex system prior to it causing failure.

Errors involving drugs must be the most common hospital safety event and it has been researched widely.  The high error rate may be because there is an over reliance on human factors with a disregard of heuristics during medication preparation and administration.  We need to avoid relying on the flawed human aspects of decision making.  When making rapid decisions we apply cognitive shortcuts. An example would be reading the first few letters on a familiar looking vial, kept in the normal storage space in a container marked with the vaccine name.  So we make an assumption that this must be the right drug and we continue to the next decision. The innovative safety-vests stating do-not-disturb can reduce the pressure to make rapid decisions before the next interruption.

I certainly felt that I could relate to this incident.  It could’ve been me making the error.  I wish that I could say that I always do rigorous medication checks; or that I trust my own decision-making towards the end of a twelve hour shift with limited breaks.  I wish that I could say that at the end of back to back shifts I’m still as conscientious as during the first shift.  I wish that I could say that frequent interruptions do not affect the task that I’m busy with.

 In summary

According to statistics by the Institute for Healthcare Improvement approximately 5% of medical error and harm is caused by incompetence or negligence.  The other 95% involves conscientious, competent and possibly caring individuals.  Mistakes such as this error were probably caused by a bad system and not a bad healthcare professional.

There is a saying that: “a bad system will beat a good person every time.”

Florence Nightingale’s other legacy: innovator in descriptive statistics

“To understand God’s thoughts we must study statistics for these are the measure of his purpose” Florence Nightingale

The lady with the lamp….Florence Nightingale is best remembered as the pioneer of modern nursing. What is less known about Florence is that she was deeply committed to the field of statistical analysis in health care.   So much so that Florence was in 1859 elected the first female member of the Royal Statistical Society.  Florence was an innovator in the field of descriptive statistics and she was part of a transformation that showed how social phenomena could be objectively measured and subjected to mathematical interpretation.

Nightingale realized that she had to make data come alive to effectively convey a message; one of her persistent messages was that health care facilities needed to improve. Nightingale held the belief that visual aids and graphs should be easy to understand.  She believed that Queen Victoria and parliament who were not accustomed to statistical data would not understand traditional statistical reports.  So Nightingale innovated and developed the polar area diagram; occasionally called the Nightingale rose diagram.  This was an innovation on the pie chart, invented by William Playfair in 1801.

She was the first person to use visual presentations to report the conditions of health facilities. Data that she presented visually to implement health care reform includes the illustration of seasonal sources of patient mortality in military field hospitals, graphs to report on the nature and magnitude of conditions of medical care in Crimean war, bar charts to show how soldiers living in barracks in England were dying at a faster rate than civilians in the cities around them because of sanitary conditions. She used the visual graphs to demonstrate how mortality could be decreased and after implementation of her recommendations how it was decreased.

“…for me this experience emphasized the great importance of correct hospital statistics as an essential element.” Florence Nightingale

Nightingale was the first to use systematic documentation of deaths in hospital, using the records to calculate death rates due to different causes.   She convinced the politicians of the role of statistics in government pointing out inconsistencies in data such as mortality rate measurements that needed standardisation.  She then took it one step further designing a hospital statistical form for hospitals to collect and generate consistent data.

“…of what use are statistics if we don’t know what to make of them?” Florence Nightingale

Data visualization is the modern branch of descriptive statistics. It involves the creation and study of the visual representation of data with the goal of communicating clearly and efficiently.   It can be used in health care improvement to indicate what should happen and what are happening.

It is not recorded whether nursing documentation existed before Florence used it to drive improvement of care in hospitals and I think that she was the first nurse to use nursing documentation. Her aim with keeping nursing documentation was to illustrate the implementation of doctors’ orders and to use nursing documentation data for statistics on hospital environment, patient safety and quality of nursing care.

It is as imperative now as it was then that nurses should use documentation to push for change and improvement. Nursing documentation should not only be limited to patient care it should extend to drive health care change in the hospital environment.

Health care practitioners are already experts at using visuals to present patient information by taking real time clinical measures of patients, presenting it on charts and then using it to make decisions, implement actions and measure effectiveness. For example vital signs charts, input and output charts, temperature charts, pressure area charts, medication charts.

“Not that the habit of correct observation will by itself make us useful nurses, but without it we will be useless.” Florence Nightingale

We also intuitively understand the importance of taking the right measure and an exact measure. We don’t report that the patient has an ok blood pressure or mild blood pressure.  We don’t expect “some” temperature or “slight” outputs.  We know that if we are to care for the patient to the best of our ability exact measures and trends are important when interpreting charts and vital signs.

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” Florence Nightingale

We need to follow Nightingales guidance and use visual data to improve health care as a greater whole.  Innovating on her concepts and using functional visuals to plan our actions better and at a glance know where the bottlenecks could direct our daily work.  Imagine how we would or could perform if we had this data available to us throughout the day.  I can just imagine the state of nirvana for most emergency nurses glancing at the information and knowing that the EC does not need to overflow with patients because the wards are discharging and there is space for our patients….mmmm…what a happy thought!

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A little note: this blog was supposed to be on the visual management of data for improvement, I completely ventured off the topic when I started reading about Florence Nightingale. I’ve read her work on nursing before and visited her museum in the UK, and I’ve always been aware of her nursing accomplishments. Somehow I missed the significance of her other work! They reckon that she was the driving force behind most health related legislation in England for a period spanning more than 50 years, she was instrumental in developing nursing in other countries, health care reform in India, and I could go on and on.  It is mind blowing that one person could impact change on so many levels.  Such an inspiration!  And they reckon that there are more than 300 Nightingale biographies alone!

Healthcare, the elephant in the room?

This past weekend I attended interesting debates at the Franschhoek literary festival.   Some discussions I attended were around politics. Areas addressed were party politics, opposition parties, political leadership, strength of parties, potential focus areas for political parties. It was insightful and repeated priorities included governance, trust in leadership, economic growth, education, social grants. Well-known names included Max Du Preez, Prince Mashele, Eusebius McKaiser, Salam Badat, Richard Calland, Stephen Grootes and Adam Habib.

I know that none of the above authors/speakers has a focus on healthcare, access to healthcare, health system functioning or potential impact of not having a functional public health sector. However I still find it interesting that there was no mention of health care manifestos or the importance of healthcare as a political tool. Think Obama 2008 and Obama 2014…it even feels strange not to type Obamacare. Affordable health has been a key concept during Obama’s campaign and subsequent presidency. In the USA Healthcare has consistently been in the news and has in many ways been a political driving force.

I agree that education, transformation and economic growth are vital to our country. However I can’t help but feel that healthcare should at the very least share an equal priority with the above and that it deserved mention.

Health systems offer value beyond health and impacts on quality of life, which includes other related factors such as level of income, nutrition, environment, safe water and sanitation. Health systems are widely recognised to be vital elements of the social fabric in every level of society.

We all require baseline health to be economically productive or to attend school. Should we or a family member fall ill we have an expectation that one should not need to spend an entire day at a clinic or an entire month’s income on medication. Our jobs should not be threatened as at it is for some because off spending a day in a queue at a clinic for medication. It should not be disruptive to our daily routine to attend to a clinic for cough medicine. Neither should out of pocket purchases financially ruin us and be unaffordable.

Beyond the debates at the literary festival, analysing the political party manifestos of the six bigger parties for the May 2014 elections the main priority areas across the parties focused on job creation, safety, education, skills development, entrepreneurship.

Yet again healthcare was typically mentioned close to the bottom of the lists and some parties only had a one-liner discussing their views on health care. Is this enough? In 2011 Healthcare was the third greatest expense of the South African government, and yet healthcare is not mentioned as a top priority on the manifestos?

In South Africa healthcare access for all is constitutionally enshrined but we need to consider whether we are failing.

  • We don’t have enough beds for sick people.

The amount of beds per population in the public health sector has declined. In 1986 during apartheid the bed: population for black people was 4.2 per 1000 persons and for white people it was 8.2 per 1000 beds. The current ratio in the public sector is 0.9 beds per 1000 people. When private facilities beds are included it’s only 1.6 beds per 1000 persons. (National Care Facilities Baseline Audit 2013)

  • We have more people and fewer beds. 

The population growth rate in 2012 was 1.2% with an estimated 52 million people living in South Africa. In 1995 the population   was estimated to be 41 million.

  • Health expenditure has not changed.

According to the World Health Organization in 2004 our government spent 8.4% GDP on health. In 2010 our government spent 8.4% of GDP on health. So effectively we might be spending less on health.

  • We have fewer medical practitioners.

Medical practitioners in 1998: 6.7 per 1000 people. Medical practitioners in 2011: 4.5 per 1000. It is estimated that most of them are working in the private sector.

  • Our nurses are old.

According to the South African Nurses Council in 2005 36% of all nurses registered were over the age of 50. In 2013 45% of all nurses registered were above 50 years of age. This is potentially disastrous as these nurses are likely to retire in the next 10 – 15 years.   Only 4% of all nurses registered with the council are under the age of 30. Nursing is just not an attractive career option.

Ignoring the importance of a healthy society seems to be a global trend. Service delivery sectors in Africa received 70% of the foreign direct investment in 2012. However Healthcare investments were not even listed within the top ten sectors to receive investments.

So my question is: is it healthy to ignore health care?