* Tel.: þ44 0E-mail addr

1355-1841/$ -doi:10.1016/j.

Journal of Neonatal Nursing (2009) 15, 159e163

www.elsevier.com/jneo

A challenging job

Karen Hoover*

40, The Crofts, Castletown, Isle of Man, IM9 1LZ, United Kingdom

Available online 22 July 2009

KEYWORDSQatar;Neonatal intensivecare unit;Nurse education;Evidence-basedpractice

1624 822610, þ44 0162ess: lkvhoover@hotmai

see front matter ª 200jnn.2009.07.002

Abstract In 2006, my husband took up a contract for 3 years work in the smallstate of Qatar in the Middle East. I joined him with my 6 year old daughter. It meantme leaving my position as a neonatal nurse practitioner, a job I really enjoyed, and Iknew from previous years working in the Middle East, it is very different forneonatal nurses there.ª 2009 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

The NICU in Qatar

The capital of Qatar is Doha, and most of thepopulation are expatriates; many of them from theIndian subcontinent or other Arab countries.Although there are many small private hospitals,main care for the whole state is provided by thelarge government owned Medical Corporation. Thematernity hospital has 12,000 deliveries per year,which increased to 14,000 by the time I left. Thereare 16 delivery rooms, and up to 40 deliveriesa day.

Families are large, with mothers marrying in theirteens; consanguinity is an accepted practice, andterminations for fetal anomalies are uncommon.There are high rates of assisted conception, result-ing in large numbers of multiple births.

The Neonatal Intensive Care Unit (NICU) has 71cots; 27 for intensive care, 10 for high depen-dency, and 34 for special care. The babies ranged

4 354099 (Mobile).l.co.uk

9 Neonatal Nurses Association

from extremely preterm (23 weekers are routinelyresuscitated) to those with all types of medicaland surgical conditions, many of them very rare. Alarge percentage had major congenital anomaliesand syndromes. Although cardiac surgery was donein paediatrics, the babies remained on NICU untilthen, and returned afterwards if paediatric ICUwas full. However, a number of babies with majorcardiac conditions were transferred to London forsurgery. The unit also has a small operating theatrefor retinopathy surgery, and ductal closure, andunstable babies with diaphragmatic hernias ornecrotizing enterocolitis were operated on thereas well.

The unit was staffed by 180 nurses who hadtrained in the Philippines or India, and none ofthem were trained in specialty. They are poorlypaid by our standards. Many of them had been inthe unit for years, often from soon after theyqualified. There was a Head Nurse for Intensivecare and high dependency, and another for specialcare. Each area had their own senior nurse team,but the other nurses rotated throughout each area

. Published by Elsevier Ltd. All rights reserved.

160 K. Hoover

every six months. They all worked 8 hour shifts,with 3 shifts per day.

The doctors were all from Arab countries, withonly a few ever having worked in western coun-tries; most having worked in the unit for manyyears. There were five consultants, each with theirown medical team.

The unit was frequently over capacity, particu-larly in the special care area with up to 6 babiescrowded into 4 cot spaces. The intensive care arearegularly had up to 18 ventilated babies, althoughNCPAPcouldhavebeenusedmorethan itwas.Babiescould not be transferred to other units when the unitwas full, because there wasn’t one. Not surprisingly,the nosocomial infection rate was very high.

Although nurses in intensive care usually hadonly one very sick or ventilated baby to care for,this was often not always the case, and chronicunderstaffing meant they often had to come in towork on days off, and work double shifts, resultingin high rates of sick leave, and staff dissatisfaction.

What was I letting myself in for?

Soon after I arrived in Doha, I called the Director ofNursing to enquire about possible work. I have beena neonatal nurse for years, and qualified as anAdvanced Neonatal Nurse Practitioner (ANNP) in2005. I was told ANNP’s werenot used, but would I beinterested in a post as Nurse Educator for NICU? Thispost had been requested by the 2 Head Nurses of theNICU for several years, but had never been filled.

It is difficult to recruit experienced, westerntrained nurses to Arab countries now, because thesalaries, although tax free, are not as high as theyused to be, and do not compensate for therestrictions, and difficult working conditions. But Iwanted to work, so I accepted the position. I wouldbe a grade higher than the Head Nurses, giving mesome autonomy, and a sense that I was movingforward in my career. However, it took 6 monthsfor the paperwork to be completed. There is a lotof administrative red tape in this part of the world,and the system works very slowly.

When I finally started, I was told by NursingAdministration that thatmyrolewas to ‘educate’ theNICU nurses because the medical staff blamed themfor the high nosocomial infection rates. I was also to‘bring them up to date with current practices’.

The enormity of the nurses’ workload

It wasn’t hard to see why the infection rates wereso high from the first day I walked in. I decided to

look at the special care area first, as it seemed tobe the one area with the most problems.

The special care area was extremely busy, withthe nurses caring for up to 4 babies each, and almostconstant admissions. Many of these babies wouldhave been on the postnatal wards in the UK, but thepostnatal nurses were not midwives, nor did theyhave nursery nurses, and they had huge workloadsthemselves. Therefore, any baby needing photo-therapy, tube feedings, IV antibiotics, or below 36weeks for example, were all admitted. As well asthese babies, the nurses were also caring for babiestransferred from high dependency, and those whobecame sick on the postnatal wards. There werealso many babies with chronic conditions who wereunable to go home due to no home care facilities,and paediatrics rarely had beds for them. Intensivecare was busy, but at least the nurses got to sit downsome of the time, they never did here, half the timethey never even got a break!

The amount of paperwork the nurses had tocomplete each day was colossal, a lot of it wasduplication and unnecessary, but it was a systemset in stone, and I had no hope of changing it.

I wanted to know if some of the admissions tospecial care could be reduced, so I did an audit.I found that there were a large number of babiesadmitted for ‘observation’ that could remain onpostnatal ward. These included infants of diabeticmothers for ‘early feeding’, and babies withmeconium staining, but no respiratory signs. Theproblem was that the doctors did not trust thepostnatal nurses to observe babies properly, and toreport any concerns. However, this did not justifyadmitting babies needing ‘observation’ to specialcare, with subsequent separation from theirmothers. I presented the findings to the consul-tants, and they agreed to question such admissionson the ward rounds, but little changed.

I ran some intensive teaching sessions for thepostnatal nurses on recognition of signs of illness innewborns, and although they were very responsiveand appreciative, I am not sure this really madea difference. There were 300 postnatal nurses, Icouldn’t teach them all, and with my own workload,I couldn’t continue to give these sessions. I was theonly Nurse Educator in the maternity hospital.

The whole ethos of the unit (and the hospital)seemed to be crisis reaction, in that a reaction toa problem happened when there was a crisis, butonce the crisis settled, the old ways of workingreturned, until it led to a crisis again. So, when theunit was full, and infection rates high, doctorstended to be stricter regarding admission criteria;when the unit had cots, they erred on the side ofcaution, admitted more, and infection rates rose

A challenging job 161

again. This process was repeated time and timeagain, and while many admitted it was happening,and set up yet another committee to deal with it,nothing happened or changed.

I tried other avenues, such as proposing to traina team of postnatal nurses who were responsibleonly for baby care (similar to nursery nurses), sothat babies needing tube feeds or phototherapycould remain on the wards, and although this wasaccepted in theory, it remained at that stage evenwhen I left. The main problem was lack of staff,but it was a never ending problem, because eachyear the delivery rate went up, and the employ-ment of new staff got caught up in this. It is now atthe stage where an even bigger maternity hospitalis being built!

Nurses in all the areas of NICU were responsiblefor incubator cleaning (this included the Giraffeswhich were used in intensive care), and this tookup a large amount of their time. There werea small number of nurse aides, but these men wereresponsible for taking blood samples to the labo-ratories (there was no pod system), stockingsupplies, and many other chores. Again, it was lackof staff. However, aides were easier, and cheaperto employ than nurses, and I felt this wasa priority. Nurses being away from babies to cleanincubators when they were already working undersuch pressures seemed ridiculous, and must becontributing to the high infection rates. The HeadNurses supported me in this, and we were able toprepare the endless letters and recommendationsto various committees, and yet it still took overa year before some new aides arrived, weretrained, and took over the cleaning.

The neck roll problem

The babies were all positioned flat on their backs,on starched sheets on a hard incubator mattress,limbs outstretched, with neck rolls to extend theirnecks. Prone positioning was not an option for thepreterm infants, and they were all repositioned 2hourly, even the sickest and most unstable.

I was lucky that there was an excellent Cana-dian physiotherapist who had worked in the unitfor 7 years, and had tried many times to introduceprone positioning, minimal handling and nesting,but the nurses were very resistant to change, andsince she was not a nurse, they refused to accepther recommendations.

Most of the nurses had worked in this unit foryears, nearly all the senior nurses for over 20, and itwas very difficult to change practices that had beenin place for years. Younger nurses who came from

other, more progressive units in the Gulf tried to,but had to accept ‘we have always done it this way’.

Together with the physiotherapist, I starteda plan of demonstrating nesting; there were nopositioning aides, so I improvised with a folded uptowel covered with a soft sheet (which I had topersuade the laundry to provide on a regular basis)and rolled up sheets to make a nest. We gavepresentations on developmental care, andevidence-based practice, and encouraged thenurses to use nesting, prone positioning, remove theneck rolls, and to handle the babies less. We didweekly rounds for auditing, and with continualencouragement and demonstration, some of thenew practices were implemented. The nesting wasimmediately successful; the nurses thought thebabies looked comfortable, and were more settled.The prone position was difficult for them to acceptas they felt the babies needed neck rolls to maintaintheir airway, and this wasn’t possible in prone posi-tion. We managed to get the nurses to at least makesmaller neck rolls, as some wereas large as thebaby!

There were some funny moments, like catchingsome of the nurses hurriedly hiding neck rolls whenI unexpectedly walked in, and insisting they neverused them! Finally, after a year of trying, and largeneck rolls still in evidence, I threw them all out(including the hidden ones.) in a grand ceremony.That immediately reduced the usage because ittook a lot of time to make them up! Getting rid ofthe neck rolls meant they considered the proneposition, and once they finally accepted that neckrolls were not needed, prone positioning becameas established as the nesting. And the neck rollsfinally disappeared.

Introducing minimal handling was just as hard.The nurses felt they werebeing ‘lazy’ if they handledthe babies less than 2 hourly, or they might get‘pressure sores’. No amount of evidence I presentedto them could change their minds; so in the end Iwroteanewpolicy.However, I couldonlyget4hourlyrepositioning accepted when it was presented to thecommittee. Any new policy had to go through manycommittees, and signatures before it could beapproved, with endless demands for amendments,so writing or changing one was not undertakenlightly. However, once it was changed, it was rigidlyfollowed, which of course had its own problems.

The parents

Parents were not encouraged to touch or hold theirbabies, particularly in intensive care, andkangaroo care was unheard of. Mothers sat at theincubator side looking terrified, and often tearful,

162 K. Hoover

with no-one to comfort them. Things improvedwhen an American social worker who spoke Arabicwas employed, but this was one woman who wasonly available during normal work hours. Therewere many parents who needed someone at nightfor example, and this had to be the nurses.

It was very difficult to teach the nurses how toshow empathy to the parents; they had enormousworkloads, and saw the parents as adding to this.They felt the mother handling the baby wouldcause deterioration, yet they failed to see thatthey over handled the babies themselves! Themedical staff did not support the concept either,which added to the nurses’ reluctance.

The physiotherapist and I tried hard toencourage the nurses and the doctors to let themothers interact with their babies, to touch them,hold them and help with their cares, and thatultimately, this would help their workload, andreduce the stress for the mother and baby.Although we achieved some successes, sadly, itremained unusual for the staff to encouragemothers to handle their babies, it was just toomuch of a paradigm shift for them to accept.Kangaroo care is still a concept far in the future.

However, the physiotherapist has finally beenaccepted as a team member, and she continues topromote and encourage the nurses to let mothershandle their babies. Persistence will pay off in theend.

The hierarchical system

There was a strict hierarchical system in NICU, as itwas throughout the hospital. For everything theydid, the doctors needed the nurse for assistance;doctors never set up a procedure trolley alone(and certainly never cleared it away!), nor did theydo procedures without the nurse on hand. Theywould sit at the bedside and shout ‘Nurse! Get methe chart!’ or whatever they wanted at that point.This was a battle I could not win; it was very muchcultural; even the nurses accepted it, as it was thesame in the countries where they had trained.

Everything was ‘ordered’ so that nurses couldnot reduce oxygen settings without an order, or doa blood gas. The nurse would call the doctor if shefelt a blood gas was warranted to obtain the order,but the doctor might be busy elsewhere, and thisresulted in babies with long periods of hyper-oxaemia and hypocarbia for example. Nurses werenever asked on ward rounds how the baby was, orshould feeds be started for example, and if thenurses made a comment (few did) they weregenerally ignored.

Although the nurses were not fazed by caring forthe sickest, most unstable baby with numerouslines, and pieces of equipment, they had very littleidea of why they were doing things, or even whatwas really wrong with the baby. Subsequently,they never questioned anything, and blindly fol-lowed orders, sometimes with disastrous results.

The teaching plan

When a visiting medical team from London askedwhat concerns I had about working in NICU, Imentioned the strict hierarchical system betweenthe nurses and doctors, and how I wanted tochange it. I wanted to promote mutual respect andteam work, ultimately improving care of thebabies, but wasn’t sure how to. They suggestedthat education was the only way; education givespower, and if the nurses are knowledgeable, theywill question practices, and this will increaserespect from the medical staff. They also recom-mended that I include the doctors in the teaching.

I was aware of findings that very low birthweight babies in neonatal units have a betteroutcome if the nurses are trained in the specialty(Hamilton et al., 2007). Therefore, I knew it wasimportant to get these nurses, who althoughextremely experienced clinically, to understandand question what they were doing, and was itensuring the best possible outcome for the baby?

I decided to move out of the clinical area toconcentrate on an education program of evidence-based neonatal nursing. I prepared a series oflectures to encompass a broad range of knowl-edge, based on what I had been taught in myneonatal nursing course (the old ENB 405) and myneonatal nurse practitioner course. For thosenurses who could not attend due to familycommitments or being on duty, I showed them howto register with Nicuniversity (www.Nicuniversity.org), the online American website which providesfree presentations, and certificates. I did not wantany of the lectures to be mandatory; adults needto want to attend if they are to learn, and I wantedto offer options as to how they did it.

I gave 2 different lectures each week, andrepeated them on a circular basis to enable asmany staff as possible to attend. I also asked thedoctors to volunteer to give lectures, and waspleasantly surprised when so many came forward.However, they were not so keen on preparing theobjectives and learning outcomes to enable us toassess learning! One of the consultants did somewonderful practical sessions on ventilation, one ofthem using balloons to demonstrate how

A challenging job 163

surfactant works, and his were definitely the mostpopular. I was lucky that the physiotherapist washappy to take on lectures, and practical sessionsemphasising developmental aspects of care,something she was an expert at, and this helpedreduce my workload.

This was a hard job for me to do alone, and Ispent a lot of time writing up objectives, photo-copying hundreds of handouts, and organising thetime and the room. I also had to prepare or updatemy own lectures, and often went home exhausted.However, it was all worth it; the nurses wereincredibly keen to learn, firing questions duringeach session, and large numbers turned up forevery lecture, many after night shifts or on daysoff. To assess their knowledge, I prepared casestudies from our own patients, which we discussedat the end of each session, and encouraged themto come to sessions with questions about the topicbeing discussed.

There were many things that the nurses did nothave access to at work; neonatal nursing journals,a library, access to the internet; so I had to providewhat I could, and it was usually in the form of pho-tocopied handouts from my textbooks, or journalarticles. The doctors were all paid to attend aninternational conference every year, but there wasno budget provided for nurses. At least all theresearching, reading, and preparing lectures I didcertainly kept my education up to date.

I realised as the months passed that the Londongroup had been right; the nurses told me the doctorswere starting to ask their advice about startingfeeds for example, something they had never donebefore. The medical staff also started to praise thenurses, and listen to their concerns, and theconsultants started to include them in ward rounds.Finally, just before I left, a visiting team rana neonatal transport course, and all the nurses whoattended achieved higher points in the examination(by a wide margin!) than the doctors did.

Thankfully, the teaching was seen as importantenough to allow it to continue when I left, and oneof the senior nurses, who had experience inteaching in India, took over, after working with mefor a few months.

Moving on

By encouraging the nurses to question practices,and teaching them the basics of evidence-basedpractice brought about changes faster than I couldachieve alone, and hopefully, that will continue.For example, one noted that extremely prematurebabies were hypothermic on admission, eventhough they were wrapped in plastic in thedelivery room. She thought this might be due tohats not being applied after birth, and imple-mented this practice with a group of colleagues.This worked, and babies were admitted with hatsin place and normal temperatures, but shecontinued to audit until the practice was fullyimplemented.

Another group of nurses questioned why theywere flushing gastric tubes after feeds with water,and surely this would adversely add to a smallbaby’s fluid intake? This was an example of anoutdated practice that had been in place for years,and never questioned before. This demonstratedthat they were starting to think about what theywere doing, and was it the best thing for the baby,i.e.; was it evidence-based? I had achieved myaim.

Conclusion

I left after 2 years to return to the UK with myfamily, and on my last day the staff held a hugeparty for me. Although it was a job full of frus-tration, and many times I went home despondentand demoralised, I also went home just as manytimes full of achievement, as I felt in my own way,that I had made some changes to help the babies,their parents, and the nurses. Maybe, just maybe,these changes will continue.

Reference

Hamilton, K.E., Redshaw, M.E., Tarnow-Mordi, W., 2007. Nursestaffing in relation to risk-adjusted mortality in neonatalcare. Arch. Dis. Child Fetal Neonatal Ed. 92 (2), F99e103.

Available online at www.sciencedirect.com