SHOULD THEY BE TREATING MORE THAN COUGHS, COLDS?

By Carol Natukunda

He lay motionless in his bed. His friends went to wake him up, only to meet the shock of their lives: He was dead.

On January 27 2009, the night before he died, Ashraf Mutaawe, 16, a Senior Three student at Kibuli Secondary School was normal. He had played basketball with his friends until about 7:00pm. After the game, Mutaawe complained of pain in the chest. Although the boy was treated at the school’s sickbay, a post mortem report by Mulago Hospital said he died of a blood clot.

The issue brings to light a debate on how efficient today’s school nurse is. Nurses are increasingly finding themselves swamped with medication for complex diseases they cannot handle. The job of the school nurse has become more demanding as society’s expectations change.

Schools are now facing a difficult question: Can a school nurse serve the purpose anymore? When Beatrice Apalat was a little girl she longed to wear a white nursing uniform and a little hat, but that is not what she works in now. Instead, dressed in a faded kitenge, she looks like she could be her school’s cook.

Changing roles
But the uniform is only one of the many things that have changed about her job.

Gone are the days when she only treated coughs and colds and cleaned and bandaged bruised knees. Now, the 45-year-old must do much more. “I think there are more diseases today than in the past. Diseases like blood pressure were for the older people, now even some children develop them. Children are obese and cannot do anything without panting, this is sad,” Apalat says.

For Gertrude Akello, a nurse at Bright College Wakiso, her daily routine is the same: “What happened to you?” she asks as she holds a tray of plastic containers and cups of water, dispensing tablets to ailing children. “Speak up! What is wrong with you?” There is a mixture of sympathy and reproach in her voice as she asks the same question over and over again.

She surveys a young girl whose head is buried in her palm. “Here is panadol, okay?” Akello says and moves on to the next student complaining of fever. “Fever? Here have chloroquin!” And just before she attends to the next child, another child comes in vomiting.

The sickbay is stuffy, with a smell of medicines hanging heavy in the air. Akello, who has worked as a school nurse for nearly 18 years, moves deftly among the queue, assessing different ailments and processing paperwork, including permission slips for those she intends to refer to the hospital.

Aside from the complicated diseases, she must be prepared to handle teenage pregnancies, deal with menstrual cramps and HIV/AIDS. School nurses also spend a lot of time dealing with trauma and depression cases, in case a school does not have a counsellor to provide mental therapy.

For instance, some students come to Akello just to talk, seeking answers to non-academic problems. “They talk about everything from being pregnant to wanting to stay home from school yet their teachers or parents do not believe they’re sick,” she says.“Some children complain of illness just to get out of class, but it does not take long to figure out that they are okay. I am glad that they trust me, but the problem is I am overwhelmed.”

Heavy workload
Besides, a growing push by the Government to move children living with disability into regular classrooms (inclusive education) also means that school nurses have to attend to children with particular needs. These include those who cannot feed themselves, or go to the toilets by themselves. In some rural areas, nurses cover as many as five or six schools. And children have been known to wait as long as an hour outside the dispensary to get their medication.

All these changes have left some nurses longing for a long-gone era which was simpler.

“If someone comes in for cough syrup, I sigh with relief. That is easy,” says Proscovia Tamale, a part-time nurse in Mukono.

The procedure for a sick student to leave school also involves substantial bureaucracy. Students can only leave after the nurse has failed to handle the condition.

At Nateete High School, parents must be called to transport the child to the hospital, if the nurse cannot deal with a case. “It is easier that way,” says the director of studies, Rose Lukwago. “When students are joining the school, we ask them to provide the contact of the nearest person or their next of kin, in case of emergency.”

There are reports of some students being sent home, by themselves on commuter taxis and boda bodas, although many schools deny it happens.

At Aidan College Ndejje, the school stocks drugs for common illnesses like colds every term, on recommendation from the doctors at the nearby health centre. The nurse administers the drugs.

“If the nurse says she cannot handle the child, we go to the health centre. If the child is admitted, we call the parent,” says Emmanuel Sempala, the school director. He explains that some parents prefer to take their children elsewhere for treatment. But in most cases, the nurse and matron help the child to cope especially where only bed-rest is needed.

At one school in Kampala, students must ensure that their permission chits are signed by doctors before they return to the school, so that the nurse can gauge if the child was not pretentiously calling in sick. In addition to handling daily sicknesses, the nurse is responsible for screening the school’s 1,000 students for vision, hearing and weight.

Schools cutting costs?
But while nurses’ responsibilities have increased, critics believe schools are frugal with their budgets and are cutting costs by hiring local and retired nurses without modern training.

“People want to spend less, because maintaining a well-qualified nurse is expensive,” observes Justus Timbigamba, the former secretary of the Uganda National Association of Student Nurses and Midwives.

While the average nurse’s pay is at sh200,000 per month, schools often have to part with a minimum of sh500,000 per month for a highly-qualified nurse. “That is why you find many schools stick with old and retired nurses, who cannot ask for too much money,” argues a parent. His colleague adds: “I think they are not bothered about our children.”

Shortage of nurses
However, there is a more glaring problem. Although the country has over 32 nurses training institutions, the Global Health Workforce Alliance last year noted that Uganda was one of the developing countries faced with brain drain and acute shortage of nurses.

The alliance noted that out of 28,064 student nurses trained in Uganda since 1970, only 16,739 were registered, implying that some might have gone for greener pastures or shunned their professions.

Uganda’s current nurse/patient ratio is 1:1,000, far below the World Health Organisation standard of 1:2 for fatal illnesses and 1:5 for common ones. To fill the gap, says an official from the nursing council, Uganda needs 68,000 nurses. It is not clear if this estimate includes school nurses.

Policy
The irony is that the education ministry’s minimum basic requirements and standards are silent about school nurses. It only highlights a well-equipped first aid unit, personal hygiene and school sanitation as the main health development indicators.

“School nurses are some of the non-teaching staff schools are at liberty to recruit,” says Aggrey Kibenge, the education ministry spokesperson. “We do not have a specific policy, but we expect schools to ensure safety, proper health and wellbeing of the children.”

“If something goes wrong, or wrong medications are given, it is the nurse that would be blamed. So a parent might sue you,” says Dr. Alfred Driwale, the Koboko district health officer.

Some also question the wisdom of reducing school nurses’ roles rather than hiring more nurses. “I think the issue is to hire more qualified nurses,” says Timbigamba.

Other countries’ experiences
In South Africa and Rwanda, there is a growing move to improve nursing education such that it translates into delivery of more cost-effective care in schools.

In the US, school officials are proposing that individual nurses be given permission to delegate the distribution of their medication to handpicked, supervised staff members. The proposal has prompted protests from many nurses, who believe the solution does not lie in reducing their roles. They argue that despite their hectic days, allowing someone else to distribute the medication — even though it would be under the nurse’s training and supervision — is risky.

Ugandan professionals also oppose the idea, in part, because it means giving up some control while retaining liability if something goes wrong.

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A day in the life of a school nurse

By 8:00am, 55-year-old Patricia, a school nurse is pacing up and down the corridors.

‘‘Be careful,” she warns 10-year-old Tracy who is walking with her face blindfolded.

Patricia hurries to the sickbay to take the temperature of a child who she left waiting for her. But before she can do that, Tracy comes in crying:. “My ankle is injured! I fell down.”

Obviously angry, the nurse raises her eyebrows and instructs the sobbing little girl to join the queue. But that is not all. An hour later, another child who has vomited arrives. “I am sick, I do not feel good,” the boy says, wheezing with each breath.

By lunch time, at least two students have come to see the nurse to say they are not feeling well and would like to call their parents to go home.

Meanwhile, those who are on treatment are still coming in to complete their doses. For Patricia, each day is hectic.