Perspectives on critical care nursing: Nigeria.

SUMMARY

* The first intensive care units were developed in Nigeria following successful management of cardiac patients at the University of Nigeria Teaching Hospital Enugu, Nigeria in 1973.

* Nigerian nurse intensivists are under the regulation of the National Association of Nurses and Midwives Nigeria and critical care units are based within departments of anaesthesia.

* The scarcity of trained nurse intensivists is made worse by the brain drain to the West.

* Intensive care nursing, in the Nigerian context, is demanding, carries a high workload, and is stressful for nursing staff.

Key Words: critical care * education * history * intensive care * Nigeria

INTRODUCTION

Generally, the health care system in Nigeria is still under development. Health care facilities are categorised into three major groups: primary, secondary, and tertiary health care facilities.

The first level hospitals (tertiary), that is teaching hospitals, are under the Federal Government of Nigeria. The second level hospitals (secondary), that is general hospitals, are managed by the state government. The third level hospitals (primary), that is 'grass root' health care centres are managed under the policy of the primary health care progamme in Nigeria and are regulated by local government. Statistics are not readily available but according to established health care policies, every major town, and every local government has an established primary health care facility. Some private hospitals are well established, competing internationally, and are better equipped and maintained than second level hospitals.

CRITICAL CARE NURSING

Intensive care nursing is the recognised term for critical care in Nigeria and intensive care nursing is a new career in Nigeria. Currently, the lack of trained personnel makes it impossible for most second level hospitals to run an intensive care unit (ICU). Some established units are being managed by registered nurses.

Another problem that is complicating the provision of ICU services is the 'brain drain' to the western world. However, it is up to us to try to solve this problem ourselves.

HISTORY OF NURSING IN NIGERIA

The origin of nursing in Nigeria dates as far back as 1846 when Bishop Ajayi Crowther, a renowned Christian missionary of the Christian Missionary Society (CMS), arrived in Abeokuta, Ogun State, Nigeria and later settled in Badagry. His place of abode is today a tourist centre.

Barely a year later (1847) the United Free Church of Scotland landed Calabar and in 1876 Mary Slessor joined and played a major role in present day nursing. In the southern part of the country the American Southern Baptist Church began work in Oyo. The Catholic Mission arrived in Lagos in 1868 and the CMS, through its outreach programme, extended their activities from Calabar to Onitsha in Anambra State that same year. It is worthy of note that all these towns were sited on the banks of the River Niger and tributaries of the Atlantic Ocean. Then, the main means of transport was by boat.

However, these missionaries believed that Jesus Christ was a physician of both body and soul, therefore healing of the sick was a way to propagate the gospel. Each missionary had a doctor in its crew. The wife of either the doctor or the vicar was a nurse. Clinics were held after the Sunday School and very sick people were kept in the missionary yard for observation until they were better.

These mission posts later became the nucleus of the various training schools for nurses and midwives, such as: Iyi-Enu Hospital Ogidi, Onitsha, Anambra State; Mary Slessor's Hospital, Itu, Cross River State; Wusasa Hospital, Zaria, Kaduna State; and Sacred Heart Hospital, Etinam, Akwa Ibom State.

CRITICAL CARE NURSING EDUCATION AND TRAINING

There is no exact date recorded when nursing education started in Nigeria, but available records show that the training of nurses began with the provision of medical and health services for the army and army personnel only. The health of the rest of the population was largely in the hands of traditional doctors.

In the 21st century, the world is becoming a global village, and in this context the nursing profession in Nigeria is aspiring towards relevance in its society through standardisation of practice, acquisition of knowledge and quality improvement.

Until recently, nursing education in Nigeria was hospital based. Systematic training started in the 1930s. Prior to Nigeria's independence, only 17% of school age children attended schools in the southern zone and 1.7% in the northern zone of the country. Recruitment of secondary school girls into nursing was rare because of the lack of schools for girls. Imomon (2001) observed that unequal opportunities between males and females in favour of males existed, and this partly explains the difficulty the recruitment of female student nurses in the northern part of Nigeria at that time. Student nurses were trained by unqualified medical/nursing personnel; with no planned curriculum. It was organised to meet the needs of the particular health care facility.

Formal Preliminary Training Schools (PTS) for nurses started in 1957 at a regional level in Ibadan, Aba and Zaria. Entry qualifications were standard six and modern three certificates. Duration of training was twelve months and six months respectively. In 1962, the Lagos University Teaching Hospital (LUTH) was the first to start an internationally recognised nurse training progamme; meriting the State Registered Nurse (SRN) certificate which, was specifically for British Trained Nurses. In 1964 the Department of Nursing was founded within the Faculty of Medicine of the University of Ibadan; awarding a diploma certificate (Imomon, 2001).

The Federal Military Government of Nigeria established a constituted body known as the Nursing and Midwifery Council of Nigeria (NMCN) (decree no. 89, 1979). The Council developed its first national syllabus for nurse training in 1960, which commenced in 1965 after a review (Ajayi, 2006). The NMCN, in August 1965, approved the curriculum of a new BSc nursing progamme and, in September of the same year, 23 undergraduates were admitted under the headship of Professor Anne Howard from Boston University, USA. The Baccalaureate programme incorporated General Nursing, Midwifery, Community Health Education and started in Obafemi Awolowo University Teaching Hospital (OAUTH), Ile Ife in 1974. Emphasis was later shifted to primary health care in 1978 (Imomon, 2001).

Recently, a new curriculum has been introduced to make nursing education more relevant and pertinent to the changing needs of the society. This revised curriculum is broad based, scientifically and technologically sound and produces a generalist nurse professional, capable of working across a broad range of clinical areas. The curriculum content includes physical sciences, social sciences, nursing science, computer science and technology, and requires a higher entry qualification than previous programmes. In the hospital based schools of nursing, five passes at credit level in West African School Certificate (WASC) or Senior Secondary School Certificate (SSSC) are required, that is, English, mathematics, and one science subject plus any two other subjects. The duration of training is three calendar years and on completion a diploma is awarded. The university requires five passes at credit level in English, mathematics, physics, chemistry and biology or other applied sciences (Ajayi, 2006). The registered nurses with diploma are qualified to continue their degree education in nursing in university to receive a bachelor's degree (BNSc). The duration of the progamme is three academic sessions.

The nurse tutor programme has subsequently been upgraded to a degree in nursing education and above to meet with the challenges of the new education programmes.

Following the introduction of intensive care nursing as a specialty in Denmark, many more countries became interested and therefore training institutions were set up. In the United Kingdom, a national course was initiated in 1970 when the Joint Board of Clinical Nursing Studies was constituted (Danladi, 2001).The board had members drawn from various professionals such as doctors and nurses interested in critical care. The terms of reference of the board included giving advice to the Secretary of State, supervising nurse training, devising and reviewing the curriculum, and carrying out other assigned functions. The first batch of trainees started the programme in 1972, and it lasted 27 weeks with minimum of 28 days theory. The remaining time was devoted to practical experience (Danladi, 2001). Although, worldwide, intensive care nursing courses were being developed at this time, this was not the case in Nigeria.

In Nigeria, several health institutions now have ICUs. The person who made intensive care nursing popular in the country was Professor Anita Oji. She was Consultant Anaesthetist and Head of the Department of Anaesthesia of the University of Jos from 1981-1988. She set up the ICU of the Jos University Teaching Hospital (JUTH) in 1982 and at the same time devised a training progamme in intensive care nursing for nurses in the hospital. Eleven trainees were admitted at the inception of the progamme, which lasted six months. The duration was increased to nine months in 1988 and to one academic session in 2000. This course has gained wide recognition and trainees now come from all over Nigeria. In 1997 the University of Abuja Teaching Hospital developed a one year progamme (Rasong, 2002). The school was accredited in July 1999 for the award of Diploma in Intensive Care by the NMCN under the leadership of Mr Ndatsu, the then Secretary General/Registrar of NMCN and Dr Menakaya, the then Minister of Health.

The entry qualification required for the programme is Registered General Nurse, basic education--WASC, GCE, SSSC with five passes at credit level in English, mathematics, biology, chemistry, physics or equivalent. The programme content includes nursing science, health education, psychology, clinical practice, anaesthesia, research methodology, computer technology, conferences, radiology, pharmacology, research works/project, and teaching skills; adding up to a total of 120 credit units.

Today there are 66 schools of nursing and nine universities offering generic degree progammes in nursing to meet the present day challenges of nursing education (Ajayi, 2006). It is sad to note that only two institutions offer a postgraduate progamme in critical care nursing.

The upgrading of critical care training in Nigerian universities and maintenance of high standard of critical care services are the key goals and vision of the National Association of Nurse Intensivists Nigeria (NANIN).

DEVELOPMENT OF CRITICAL CARE NURSING

The concept of caring for critically ill patients in a hospital side ward or cubicle began with the origin of nursing itself in Nigeria (Rasong, 2002). The modern ICU came into being in 1973 at the University of Nigeria Teaching Hospital (UNTH), Enugu following the successful management of cardiac surgery. This stimulated more hospitals to establish ICUs (Rasong, 2002). Most of the ICUs thus established were managed by experienced nurses and anaesthetists.

The need for trained personnel in the field to man the ICUs became enormous. Because the training programme was undertaken abroad only a few nurses could afford it. This was unfortunate, especially as JUTH developed the programme in 1982.

The registration and licensing of nurse intensivists did not occur until 2006. To date there is still no Nigerian degree progamme in critical care, although there are some proposals and curriculae currently under development.

INAUGURATION OF THE NATIONAL ASSOCIATION OF NURSE INTENSIVISTS NIGERIA

The graduates of JUTH School of Intensive Care Nursing held a meeting at which they discussed issues that they felt were critical to the development and standardisation of training in the School. Meanwhile, graduates of the University of Abuja Teaching Hospital (UATH) following the full accreditation of the training school were faced with two challenges: ensuring Council registration as soon as possible, and maintaining an avenue whereby conceptual issues and innovations could be discussed.

Subsequently, the Alumni Association of Nurse Intensivists UATH was founded in November 1999, when amongst others, papers were presented by Rev Sr Dr BO Azide, Consultant Anaesthetist Physician and Mrs E Rasong, Co-ordinator of the UATH critical care progamme. The highlight of their papers was their advice to reach out to other trained intensivists in the country to establish a formidable body and fight the common cause together. This dream materialised on 04 October 2002 at the bi-annual conference of the Alumni Association, held at the National Orthopaedic Hospital, Igbobi (NOHI), Lagos when the National Association of Intensive Care Nurses (NAICN) was inaugurated. The name was later changed to NANIN at the 2nd Annual conference held in JUTH.

The NANIN maiden Executive Council was established under the chairmanship of Mrs Oby Oguariri. The Council worked hard to produce a constitution within a short time. Its objectives were to set and maintain the highest quality standards of nursing care for critically ill patients and to improve members' professional skills through continuing education. A motto for the Association was established: The Nurse with Third Eye. Mrs Oguariri remained Chair of NANIN until the 5th annual NANIN conference in Kano, in October 2006.

The first Executive Committee, in their manifesto, sought to link up with the national body. The Public Relations Officer of the first Executive, Halima Kabara, worked tirelessly with due consultations with Mr H Danladi JP, NANIN Adviser and coordinator of the Post Basic Intensive Care Nursing School JUTH, and Mrs Oby Oguariri

NANIN is still a very young association with a membership of about 380 nurse intensivists. It is zoned into seven regions throughout the country for access and co-ordination. It is governed by the National Association of Nurses and Midwives Nigeria (NANMN) whose regulation does not permit registration of NANIN as a separate entity.

Today, NANIN is a recognised member of the World Federation of Critical Care Nurses (WFCCN), having been officially admitted at the WFCCN critical care congress held in Sun City, Pilansberg, South Africa in August 2007.

The NANIN Trustees are:

* Dr (Mrs) ES Isamade (Jos)

* Rev (Sr) Dr BO Azide (Abuja)

* Mrs FE Nanle (Jos)

* Mrs AA Mwanmut (Port-Harcourt)

* Dr BO Eboh (Asaba)

The NANIN Advisers are:

* Mr HM Danladi JP (Jos)

* Mrs E Rasong

PROFESSIONAL AND ETHICAL FRAMEWORK

The NMCN is a parastatal (part of government or associated with government by means of an Act) of the Federal Government of Nigeria established by decree 89 of 1979 of the Federal Republic of Nigeria and amended by decree No. 54 of 1988, No. 18 of 1989 and No. 83 of 1992. The Council is the only regulatory statutory legal, administrative body for all cadres of nurses and midwives in Nigeria.

The functions of the nurse, in the nursing curriculum (as approved by the Council), are such that each school will plan, implement, and evaluate their courses in such a way that the graduates of their programmes will be able to: collaborate with other health teams; provide health teaching; administer resources and personnel; and provide preventive, curative and supportive care to patients.

The scope of practice in critical care has been adapted from the above attributes and is rooted in the concepts of science, art, ethics and philosophy of nursing (Gofwan, 1997). The following aspects are critical:

* Ongoing assessment, screening, problem identification, Implementation and evaluation of patient care.

* Critical care nurses control standards through nursing audit and are accountable for their professional acts and omissions.

* The critical care nurse must be active in development of skills through continuing education that will develop her critical thinking and judgement.

* The critical care nurse's primary responsibility is to those who require critical care.

* In providing care, the critical care nurse promotes an environment in which the values, customs and spiritual beliefs of the patient are respected.

* The critical care nurse must hold in confidence any personal information, sharing it only if it is deemed to be beneficial to the care of the patient.

* The critical care nurse is active in developing, setting and implementing standards and policies within her organisation, in accordance with national policies. In clinical practice however, critical care nursing is under medical supervision.

PROFILE OF NURSES CURRENTLY WORKING IN CRITICAL CARE

A small study on the rank of critical care nurses in Nigeria shows that 65% are within administrative/managerial levels and 35% are in role/team player levels. Gender ratio is 2:1 in favour of females. Sample populations of these data were randomly taken from northern and southern Nigerian established health care facilities in October 2007.

Only 8% of critical care units have a full strength staff of trained nurse intensivists. Others use a pooled nurses system to augment the staff shortage and training on the job is common. A good number of critical care nurses are working outside critical care areas. Some tertiary hospitals have yet to establish an ideal critical care unit and private hospitals are using non-trained critical care nurses to provide care; often emergency department nurses are used.

CRITICAL CARE NURSING IN NIGERIA: A BURDEN OR A BLESSING?

Critical care nursing may be considered a burden when viewed from the following angles:

* Provision of modern technological devices is insufficient in most centres and furthermore, the maintenance of available equipment is problematic.

* Working environments are not conducive to practice.

* Poor motivation, poor remuneration and rigid policies encourage the brain drain to the western world.

* The care is stressful and the work conditions are more stressful. High expectancy is placed on nurses and this is demanding.

* Poor standards arise from the low nurse: patient ratio (which is below standard), pooled nurses (who are not trained), and the high demands placed on qualified nurses.

However, critical care nursing in Nigeria can be considered a blessing from the following perspectives:

* Patient recovery is impressive (over 80% at NOHI, Lagos).

* Some technical surgeries are carried out in Nigerian hospitals, which ordinarily would require international transfer. For example, renal transplant (Aminu Kano University Teaching Hospital, Kano; St. Nicholas, Lagos), heart surgery (University Community Hospital, Ibadan; University Nursing Teaching Hospital, Enugu), brain surgery (LUTH, Lagos; OAUTH, Ife; JUTH, Jos), and spinal surgery (NOHI, Lagos).

* Nurse intensivists are held in high esteem: most critical care units are tagged "miracle" centres!

* Regular debriefing sessions (utlising the Incident Command System) are used to help critical care nurses destress after particularly busy periods or major events.

THE FUTURE OF CRITICAL CARE NURSING IN NIGERIA

Critical care in Nigeria is complex with many challenges; however the current health policy and strategic health plans carry reforms that will benefit critical care nursing in the country. A number of other initiatives should also result in benefits:

* A NANIN/British Association of Critical Care Nurses (BACCN) collaboration has been established. This will help to develop critical care nursing through knowledge sharing.

* NANIN's initiation into the WFCCN will provide the driving force to improve in areas of research.

* Upgrading education in critical care will validate communique that is expected to alert attention of law makers and providers of the country in a positive manner to meet international standards.

Further reading

NANIN (2004). NANIN Constitution. Onyesanik Lithographic Productions, Lagos, Nigeria.

NANNM (2008). NANNM Constitution [Online]. Available at: http://www. nannm.com/constitution.html

NMCN (2007). Establishment Policy [Online]. Available at: http://www. nmcn.org.estab.php

Obaro Eneire JO (2004). Status of Quality Assurance and Accountability in Intensive Care Nursing Practice in Nigeria. NANIN Conference, Abuja, Nigeria.

REFERENCES

Ajayi AO (2006). Nursing Education in 21st century: a tool for patient care. Nursing Weel, Lagos, Nigeria.

Danladi HM (2001). Fundamentals of Nursing Care: For Intensive Care Nurses, First Edition. Zinek Communications, Jos, Nigeria

Gofwan TH (1997). The Laws Rights and Functions of the Professional Nurse in Nigeria. Baaji TT Business Centre, Jos, Nigeria.

Imomon L (2001). Nursing in Nigeria Problems and Prospects. Dikko Printing and Publishing Co., Abuja, Nigeria.

Rasong E (2002). Intensive Care Nursing and the Critically Ill Patient: A Burden or A Blessing. Conference/Workshop Lagos, Nigeria.

Obiageli Oguariri RNM, RAEN, RCCN; PGDHM, MMC, Nurse Administrator, Department of Anaesthesia/Critical Care, National Orthopaedic Hospital, Igbobi, Lagos, Nigeria. Halima Kabara RNM, CCN, ADLS; PGDPPA, MPPA, Research Manager\Nurse Administrator, Department of Anaesthesia/Critical Care, Aminu Kano University Teaching Hospital, Kano, Nigeria.

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