by: Fauste Uwingabire, MScN (Neonatal) RN
New discovery in my way to neonatal specialization is a personal story to share about how I did not know what neonatal care meant until I was admitted in the neonatal program at masters’ level. Because I had been facing neonatal care/ skills as part of maternal newborn package and/ or as part of pediatric package; I was misunderstanding that neonatal is included in one or both of them.
I am a Rwandan neonatal nurse specialized at Master’s level in neonatal sciences. This story focuses on my experience as a university student who was interested in nursing specialization; the long way it takes to be one of the first Rwandan nurses specialized in neonatal nursing science and today life as a qualified neonatal nurse. Before admission at University of Rwanda (UR) as a neonatal student; I had a closer influence/ exposure of specialized Pediatric nurses and I was a tutorial assistant at UR with a Bachelor of sciences in nursing. I was facilitating the child health care module and was part of the obstetric and neonatal care module. I had 5 years’ experience in teaching theoretical components of pediatric and coach undergraduate students (advanced diploma level) both nurses and midwives in their clinical mostly in pediatric wards. I was trained in combined package of integrated management of childhood Illness (IMCI) and was completely felling comfortable with the pediatric skills. At the time my view was that neonatal care is part of child health care package or maternal newborn care. When I thought about specializing, I applied for maternal newborn or Pediatric but got admission in neonatal track! This did not excite me; I felt this could not be a standing alone nursing specialty and wish it have to be combined in Pediatric or maternal to have sens! I had even written to my school administration to shift from neonatal to pediatric track but I did not succeed. I was just waiting to know what about neonatal specialization! While in the program, I realized that I am luck to be in the neonatal program as I real understand that neonatal is a very delicate domain requiring special knowledge and skills of caring sick and preterm newborns. I recognize the importance of having neonatal as a standing alone domain because it has separate and unique requirements to help the sick/ preterm newborns and their families. I realize how much child newborn or maternal newborn combined package of care end by missing/ negating the essential needs of newborns. I realized that many simple/ cost effective/ and newborns’ life-saving interventions are not applied like immediate newborn drying and other evidenced based care for stable newborn such as direct and prolonged skin to skin, delayed cord clamping, early initiation of breastfeeding, keeping the baby warm, etc.. Most of the time the delivery room personnel is directly concerned with filling medical documents so weighting, giving vitamin K, eye tetracycline, taking the baby height,…are the most priorities than initiating breastfeeding!
My first days of clinical practice in neonatal unit as a student were challenging! I could not know what to do! I was confused! Despite the theoretical knowledge had at the university; despite the past pediatric experience; neonatal unit was a new and unique environment to me! I needed a direct coach from my clinical supervisors. From this experience I realize how much it is frustrating and unsafe to just allocate a new staff (Nurse/ Midwife) in the neonatal unit! An orientation period with mentorship from an experienced (neonatal) nurse should be mandate prior to start independent work. A simple example is differentiating gestational age and birth weight where most of preterm AGA or LGA babies do not benefit the package of preterm babies because with limited neonatal knowledge some neonatal unit staff gets confused and base on weight to define gestational age which is not right!
I also realized that caring sick and preterm newborns need special neonatal skills because now days preterm and premature related complications is the leading cause of neonatal mortality in my country followed by Birth asphyxia. Though sometimes the causes of prematurity are not preventable but skilled/ competent neonatal nurses can make a difference! An effective and timely resuscitation; followed by a safe intra-hospital/ inter-health institutions transport and improved management upon admission in neonatal intensive care unit (NICU)/ neonatal unit can save life a millions preterm babies. As part of my academic requirements; I did research on Birth asphyxia! The findings were that the prevalence was at 39.7% with a very high specific mortality rate (89%) at one of the Kigali city district hospital! Though birth asphyxia occurs out of neonatal units but having skilled neonatal personnel could be a strong contribution to its prevalence reduction or to the improved management of asphyxiated babies leading to better outcomes!
Newborns being a unique group of individuals having special needs compared to the rest of health sector customers; they also need to be cared by someone having standardized knowledge, skills and competences in this domain. Newborns need someone who can understand their special language; they way of communicating that they are in pain, that the noise level is high, that they need enteral feeding, etc.
After graduation I am a UR staff and paying back in supporting the neonatal track. The nursing profession is general challenged with none existence of scope of practice especially when it come to those having advanced academic level like masters because with none existing scope of practice, they even do not appear neither on the public servants’ structure nor on the private sector. The UR is the only institution actual recognizing our level and our specialization! As graduated neonatal nurses; we had also thought about making a visible contribution to the visibility of the neonatal among other nursing specialties. I am part of the neonatal nurses’ team leading the reinvigoration of Rwandan Association of Neonatal Nurses (RANN) to have it as an official recognized association. Having RANN may help to local define the needed competences to become a neonatal nurse not only based on formal academic education but through continuous professional development (CPD) and mentoring program. We need RANN to be our local room of voicing and sharing opportunities; challenges and joys we got while caring for neonates and their families.
Actual the joy coming from my job is to see several nurses/ midwives now volunteering to specialize in neonatal nursing and at this time it is an opposite version! Many students need to join neonatal but the program abilities can’t afford a big number. In the first cohort we were 14 and have 13 in the second cohort! We have district hospitals and referral hospitals as clinical settings for our students with a very high number of newborns with various conditions but still challenged with the neonatal competences of the hospitals’ personnel working in those NICU/ Neonatal units. Most of the time there are simple registered nurses/ midwives at an advanced diploma level without any orientation or particular neonatal training! They mostly said: “I can just help your students to familiarize with neonatal vein….but I don’t understand the patho- physiology behind this newborn condition….I just execute the physician order”. We almost learnt by experience but we get confidence in what we know with expert mentorship. At me period I was exposed to expert neonatal nurses with long-term experience in the field and feel more confident when I am managing conditions I was mentored on.
I am the focal person at UR of the COINN coming conference of October 5-6; 2018 which will be hosted by my University of Rwanda.
I got another discovery through the COINN conference organization! The theme of the conference “New frontiers for African Neonatal Care” is timely! This conference organization helped me to know the extent to which Rwandan nurses and midwives are excited to learn and update their neonatal knowledge. A very big number of Rwandan nurses/ midwives from different corners including rural areas registered to attend the STABLE course! It is unfortunate that the STABLE training has a limited number of participants (150) because some will not benefit. It is an exciting step that the official university of Rwanda recognize the need of specialized nurses at Master’s level in neonatal nursing but still a long way to go and real make a remarkable contribution to the achievement of the Sustainable Development Goal especial the number three (3) target two (2) “SDG3-2” which aiming to end all preventable neonatal deaths! The rate of preventable neonatal deaths is high in lower- and middle- income countries including Rwanda. We are also luck because there is a political will to support the neonatal care. Neonatal care is part of the key priorities of the government of Rwanda through ministry of Health. The coming COINN Africa conference a great opportunity to the neonatal visibility and a part from trainings, participants will benefit to attend neonatal evidence-based practice and researches presentation; exchange with local and international, etc. I also believe that the existence of RANN will be another positive factor to the process of improving neonatal practice in the country.
There may be confusion about what neonatal nursing is or who is qualified to be called a neonatal nurse. Like from my experience, they may be people confused if neonatal nursing needs an extra special competencies apart from being a qualified general nurse. In my country Rwanda, Neonatal nursing is advancing with formal academic specialization in the domain. While moving ahead the whole world needs to understand that there is a special need of neonatal competent nurses to assess and handle sick and vulnerable newborns.