Lost lives, lost skills: The high price of failing to employ and mentor health graduates

Peggy* lay on her back, legs drawn back, tears streaming down her cheeks as she struggled to push out her precious baby. She had laboured for the past nine hours and she was exhausted beyond measure. She just wanted the baby out. The baby on the other hand, had other ideas. The second stage of labour, which is when baby comes out, was taking quite a long time, despite Peggy’s best efforts to bear down.

The nurses in the room had walked with her every step of the way as she was the only mother in labour in the unit that day. They could see how worn out she was. They set up an intravenous fluid infusion to help and when the baby’s head finally descended, they reassured Peggy that it was almost here. On her next contraction, not only did Peggy bear down but as one nurse supported her delivery, the other one applied direct pressure on her abdomen (fundal pressure) to push the baby down.

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Peggy cried out due to the discomfort the pushing added to her labour pains, but she was rewarded with a ‘pop’ when her baby’s head finally came through. The nurse let Peggy’s abdomen be and went to receive the baby. The little one didn’t cry immediately, but the nurse rubbed him down and cleaned out his airway using a suction machine before putting him on oxygen support. He finally let up and gave a weak cry, causing Peggy to shed more tears, only this time, tears of happiness. 

The nurse moved the baby to the little newborn unit that had two cots and kept him on oxygen. His breathing rate remained quite high, with a matching high heart rate, but the overall pink colour of the baby reassured the nurse and she saw no cause for alarm. The baby was never reviewed by any other medical personnel.

The other nurse finished off with Peggy’s care and transferred her from the delivery room to her bed. Peggy was so exhausted that after a cup of tea, she dozed off. She was startled out of her sleep to breastfeed the baby. However, the baby was unable to latch on and suckle as his breathing was too fast. He was taken back to the newborn unit and put back on oxygen support. Every two hours, the nurse would return to Peggy with the same purpose, and each time, the breastfeeding attempt would fail. This went on all night.

The next morning, when the clinical officer came to do the ward rounds, he was informed that there was a baby born overnight who was in the newborn unit. He decided to review him first. He found the poor little one at the brink of respiratory collapse. The referral mechanisms were activated and the baby transferred to the national referral hospital. Despite interventions, the little one succumbed to severe birth asphyxia a week later.

Aggrieved parents

The aggrieved parents filed a complaint against the hospital for the baby’s poor outcome and eventual demise. During the hearing, Peggy’s grief was palpable. She recounted her long labour, her difficult delivery and the aftermath of trying to feed her baby to no avail. She remembered the devastation on the face of the neonatologist who spoke to them, explaining that their baby had lost the precious opportunity for thermal cooling, in order to protect his brain from severe damage, because he arrived at the referral hospital too late.

Peggy wept silently, recounting the harrowing experience of watching her baby convulse repeatedly as the effects of asphyxia manifested. She lamented about how her baby never breastfed, robbing her of the joy of this simple act of motherhood. It was heartbreaking.

When the nurses took to the stand to give their evidence, what came out was even more disturbing. The young practitioners opened a pandora’s box that is fast becoming the bane of Kenya today. Both of them had completed their training and passed their registration and licensing examinations. Armed with their crisp new licences, they got down to 
the business of hunting for a job.

After a frustrating two-year job search, the starry-eyed young nurses gave up on working in their dream hospitals and took whatever came their way. This is how they ended up in a little maternity home in the city surburbs, with minimal pay and absolutely no senior supervision or mentorship in the nursing department. They were young, inexperienced and even worse, had not touched a patient in two years.

As a result, the lack of exposure not only left them vulnerable to malpractice, but most critically, left the patient vulnerable and at risk of mismanagement and even death. 
This is what happened to them when they were suddenly on duty alone, with no experienced midwife to help guide them and impart knowledge, while sharpening their skills.

The poor nurses had no idea that the dangerous practice of fundal pressure was long abandoned as it has been proven to be harmful. They failed to appreciate the critical state the baby was in. They inadvertently put the baby at even more risk every time they attempted to put him on the breast without realising that in his state, he should have been on only intravenous fluids.

They had no situational awareness to understand that the baby needed to have been referred to care immediately so as to benefit from immediate thermal cooling within four hours to minimise the brain injury he sustained. One is left to wonder what was worse; for the baby to pass on, or to survive with lifelong complications of cerebral palsy that would leave him dependent for life.

Where did we drop the ball? For any young person choosing to pursue a health-related course, they have locked themselves into a profession whose skills are not usable in other industries. They are pretty much stuck on a pathway that is difficult to change course.

What we fail to realise is that in training, a student will need to learn and practise their skill on actual patients. It is not possible to learn everything in training. At graduation, all students are expected to have met a certain minimum level; and thereafter, they will continue to learn in practice. This is one of the key drivers why the 
Ministry of Health aspired to keep the new graduates in employment, to ensure they started off under senior oversight with continued mentorship as they gained experience and imparted the same to those behind them.

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Now, with a mismatch between the number of graduates and employment opportunities, their aspiration to step into the hospital and meaningfully contribute to relieving patient suffering is quickly shattered when the country fails to plan for them.

They end up being away from the clinical areas for far too long, losing the little skill they had started to build. Even worse, they end up securing jobs in little clinics that have limited human resource complement, leaving especially the newly recruited doctors, nurses and clinical officers taking clinical leadership positions when they have no experience and very rusty knowledge.

Ultimately, the patient becomes the loser!

The writer is a gynaecologist/obstetrician