Nursing Mulago’s staff shortage

By Annah Natukunda

One nurse is expected to care for 100 acutely sick patients as ministry loses Shs400 million per year on “ghost” workers

You get up! Go and sit outside,” orders a man dressed in light blue trousers and a white shirt with a Mulago Hospital staff ID. He appears to be in charge of the seating and his authoritative voice rouses a visibly sick woman who was lying with her head on her caregiver’s lap.

The man scans the crowd of patients and their caregivers. His target is any patient who does not look too sick to wait outside. “You get up! Go and sit outside,” he says again and again to patient after patient. He has to shout to be heard above the din as he repeats the command across the room.

More patients poured in through the entrance; in wheel chairs, stretchers, or being helped to walk in. Dozens of patients crowd the reception area, many of them lying on the cold cement floor as the few seats available have already been taken. An equally large number wait outside.

A nurse passes by in her dark green apron worn on top of her uniform. When we try to talk to her, she looks around helplessly.

“I am busy. I have a patient I am resuscitating,” she says, “Talk to the matron – maybe…”  She turns and walks away quickly to attend to her dying patient. She is the only nurse on duty in sight at the ER.

That is the scene on any given day at the Emergency Room (ER), known here as the Casualty at Uganda’s largest hospital, Mulago National Referral Hospital in Kampala.

Like hospitals across the country, Mulago has a severe shortage of health workers. While the shortage of doctors attracts the most attention, the lack of nurses is the more shocking because it has now reached crisis proportions. Most nursing work is either not done, or shouldered by the interns, because Mulago is a teaching hospital.

The crisis comes at a time when the the government has just secured US$ 88 million from the African Development Bank, and the Nigerian Trust Fund to remodel Mulago hospital in a move designed to help decongest it by constructing two other hospitals in Kampala. According to the Mulago Hospital Spokesman Dan Atwijukyire Kimosho, the hospital will get a “total overhaul” through renovation. The entire electricity system will also be overhauled, and new specialised equipment bought. The money has already been approved by cabinet, and is only awaiting parliamentary approval.

But critics say that as long as the human resource is not prioritised, the hospital will continue to be dysfunctional. Human resources for health are identified as the core component of any health system.

Uganda requires 5000 health workers, particularly nurses and midwives, according to the ministry of Health. Staffing levels at the district are low at 53 percent and 56 percent at the national level. Last year, Dr Christine Ondoa the Minister of Health announced that government had set aside Shs 5.4 billion for the recruitment of health workers. This is only a drop in the ocean, analysts say.

Overwhelmed staff

Bileti Helen Nellie is the matron. She is the Principal Nursing Officer at the Accident and Emergency (Casualty) Mulago hospital and has been working as a nurse for close to 34 years now. At 58, she still runs around the Casualty helping out with the patients, even if her position is supposed to be more supervisory than clinical.

We catch up with Bileti at 3pm over a late lunch. She still manages a weak smile but her day has been particularly busy and tragic. Already two patients have died on her watch despite all the effort she put in to save them.

“I help out a lot with patients. I just came in here (office) to attend to something urgent,” she says. Looking exhausted, she stirs a cup of maize porridge that is her lunch. “I am supposed now to be instructing others, but if the ones am supposed to instruct are not there, if I have no one to instruct, what do I do?”

According to Beatrice Amuge, the Assistant Commissioner Health Services, the shortage of nurses is not new. She says each hospital including Mulago is given a medical staffing structure but the existing structure was made over 10 years ago and has been overtaken by the increasing patient numbers, the emerging and re-emerging diseases.

She says the Casualty section, which is the busiest part of Mulago hospital and receives over 1000 of the most serious cases daily, has only 13 nurses assigned to it. They handle the most acutely ill, including emergency referral and trauma patients, who comprise mostly road traffic accident victims. The workload is heavy and the nurses work in three working shifts per day.

“You can imagine how many nurses stay on duty if you have 13 nurses working in three shifts, some of them have to be off, and others may be on annual leave,” Amuge said. “On average, you have two to three nurses on duty during day time.”

At night, when it’s less busy, there’s usually one nurse on duty working from 8pm to 8am, until when they are relieved. The Casualty receives over 1000 of patients each day.0

Mulago’s status as a national referral hospital means that most of the patients received are very sick, even terminally ill. Such patients require a lot of nursing care.

“It’s actually very difficult when you are working alone, and you get two patients at the same time that need urgent care,” Sarah Kweberaho, a Nursing Officer at Casualty said. “You have to weigh which one to work on first, and it’s not easy.” Kweberaho who has been working in Mulago for 19 years but has only been in the Casualty Ward for seven months says it is the most challenging section to work at in Mulago.

On a really bad day, for instance when there has been a serious accident involving many people, then reinforcements are sought.

For each patient coming in, the nurse is supposed to take their vital signs; temperature rate of heartbeat, breathing, and blood pressure. Sometimes they have to administer the initial treatment in emergency cases as they wait for the doctor. Nurses also do the routine observations. In the process of dealing with one such patient, other lives are put at risk in a place like Mulago where there’s a shortage of nurses.

“You can have two nurses in Casualty,” Amuge said, “If you take long to reach the other patient, you find their condition will have worsened.”

In order to prevent such occurrences, Amuge says they have learnt how to quickly observe each patient as they come in and categorise as either very sick, moderately sick, or not badly off.  Amuge quickly admits that this system still has challenges as most patients at Mulago are usually very sick. That’s when patients begin to complain about poor treatment because each of them expects instant treatment.

In addition to tending to the sick, the nurses on duty are expected to ensure infection control, administer drugs and ensure that the environment is clean. They also receive and account for supplies in the unit; that is, the sundries like gloves, cotton wool, needles and syringes, have meetings, write reports, supervise each other and supervise students since Mulago is a teaching hospital.

“Imagine therefore having two nurses on the ward. You find the rest of the work undone,” Amuge said, “There’s even burn out. You run around, some patients are not easy, others are rude. In the long run, it affects care of patients.”

Mulago Hospital nurses are known for their rudeness to patients. However, in private conversation, they say sometimes it is out of sheer exhaustion.

Acute cases

The pinch is being felt more where highly specialised nurses are required such as at Mulago’s Uganda Heart Institute where nurses need to be on a patients’ bedside 24 hours. For a hospital of Mulago’s standing, they should have adequate specialised nurses. But at present, the only specialist nurses are those that have done short trainings here and there.

Hospital nurse staffing is a matter of major concern because it affects patient safety and quality of care. Low nurse staffing levels tend to result into higher rates of poor patient outcomes, generally. According to the World Health Organisation (WHO), there should be one nurse for every five patients, and one midwife to every four patients. Uganda has a nurse-patient ratio of 1:11,000 and a doctor-patient ratio of 1:15,000.

Health analysts say that given that Uganda has very few doctors, it needs more of the lower cadres, including nurses, to help with the tasks.

“Once you don’t have the required staff, many times we have seen people who don’t have the required skills for example sweepers administering medicines,” said Denis Kibira, the Medicines Advisor, Coalition for Health Promotion and Social Development (HEPS-Uganda). “That means you have ineffective drug administration, it means the information going to the patients is also not right. And once medicines are not properly used, it will lead to resistance; and ultimately death.”

Kibira says the situation of low doctor and nurse staffing is even worse at lower level health centres, where supervision is inadequate. According to a 2009 survey: Tracking Uganda’s Health Sector in Budgeting, Financing and Delivery of Essential medicines, over 50% of established positions in health centres have not been filled. But even the few places that are filled, the study shows that on any given day, 50% of the workers will be absent. The main reasons for the high rates of absenteeism cited are usually related to poor pay and motivation.

An enrolled nurse and a nursing officer earn on average a gross pay of Shs 300,000 and 500,000 respectively. Yet most nurses are not given staff accommodation, transport or lunch allowances.

Though this is arguably cheap for the government, it claims it does not have enough money to recruit the required number of nurses and midwives.

“I think there are enough schools for nurses, and enough nurses. But they are just not in the public sector,” said Denis Kibira.

Why then is government not recruiting?

According to the ministry of Health, it was the rot within the previous Mulago administration that led to the current crisis. Dr. Asuman Lukwago, the Permanent Secretary Ministry of Health says the previous administration headed by Dr. Edward Dumba concealed vital information from the ministry to cover up for the high number of ghost workers that were on the payroll. Dr. Lukwago said Mulago was losing up to Shs 400 million per year in ghost salaries.

“Now that we’re getting the information, we respond as fast as possible,” Dr Lukwago said, adding that Mulago Hospital had written to the ministry that they “were stretched.”

Dr. Ddumba was replaced controversially in March last year, alongside other senior members of his administration. Mulago Hospital is now headed by Dr. Byarugaba Baterane.

The permanent secretary said the crisis was compounded by a structure established years ago that favoured a small number of nurses. But as the population increased, the structure was never revised to suit Mulago’s needs. Lukwago said the ministry has already submitted a restructuring proposal to allow for extra staff.

“It is because of the constricted structure that does not allow us to recruit beyond a certain percentage,” Dr Lukwago said, adding, however, that the ministry was looking into the possibility of recruiting health workers outside the Health Service Commission. He said the ministry has secured “a little money” that they were using to support local government recruit health workers directly, and it is this money that they are going to use to recruit some nurses for Mulago on contract basis, to deal with the problem in the short term.

Bileti is nearing retirement, but her desire to see nurses better appreciated for the job they do remains strong. She wants the government to do more.

“There should be an effort to have staff accommodation nearby, for example, decent ones, not the ones we have up there in Old Mulago,” she says, “So I can be encouraged. How am I supposed to health educate someone when I live in a dump myself?”