Critical Care Nursing in resource-limited environments is an emerging sub-speciality, currently centred on regions within sub-Saharan Africa and South-East Asia. 
The World Federation of Critical Care Nurses (WFCCN) continues to grow. Uganda and Nepal both had inaugural critical care nursing conferences this year. You may also be surprised to learn that the African Federation of Critical Care Nurses has already had three triumphant annual conferences. 
My long-standing involvement in critical care nursing within low-income countries stems from a partnership between Health Institutions in Mbarara, Uganda, and Hull, England. This successful link was set up by The Tropical Health Education Trust (THET) and helped recreate the Department of Nursing in Mbarara. 
In 1999, I was an experienced critical care nurse and educator, who routinely cared for adults and children. These skills enabled me to thrive in the clinical and academic settings in Mbarara. Nowadays, I continue supporting Mbarara University as an external examiner for a MNS (Master Nursing Science) Critical Care and as an honorary lecturer.

Left: The cyclist with a milk churn on the bicycle rack is symbolic of Mbarara ‘the land of milk and honey... Right: Mopeds are Boda Boda (local taxi service) and they are going past a Clinic within Mbarara Regional Referral Hospital

It’s difficult to describe the continual challenges that occur while trying to provide critical care services within a resource limited environment. Staffing levels are minimalist and family members provide much of fundamental nursing care. 
Standards of care are indeterminate and necessity governs a lot of clinical practice and use of technology. Medical supplies are rarely guaranteed in the public sector. Likewise, medical technology and equipment is often problematic and less than ideal. 
I believe that critical care nurses in low-income countries need to determine indigenous and sustainable nursing practices that are applicable to their locale. Likewise, robust and well-engineered equipment that is designed for austere environments should be the used. 
As critical care units emerge in the developing world, there will have to be more consideration from fellow clinicians, educators and medical equipment suppliers about the role and responsibilities of the nurses that care for critically ill patients. 

A Need for Understanding

I’m currently a PhD candidate, studying the educational needs of registered nurses who care for critically ill patients within a Ugandan setting. Critical care nurses throughout the world often have intense memories of their induction into their critical care unit.

I am seeking to establish a level of core knowledge and skills that are generated from the perspective of registered nurses working in an ICU within Uganda.

The Operating Theatre is for General and Orthopaedic surgery

Echoes From the Eighties

Several anecdotes have continued to influence my concept of critical care nursing in resource limited environments and sadly, they all come from the 1980s!

Firstly, the Army Medical Services in the 1980s was influenced by the Cold War and we readied ourselves for a high-intensity conflict. It was determined that mass casualties would receive medical and surgical treatment in Field and General hospitals, based in improvised locations.

The ethos was to prioritise casualties and provide rational treatment, as appropriate to each case. The equipment provided was sufficient to ensure adequate anaesthesia, surgery and rudimentary critical care.

The Army Medical Services used its own specific methods and treatment regimes, as opposed to mimicking civilian practice in ‘expensive care units’ within the UK. These memories of a functional and adequately equipped service convey a sense of utilitarianism that is analogous to a critical care setting in a low-income country.

It was also apparent in the 1980s that medical equipment was more mechanical in operation. Companies like Diamedica have continued to produce equipment that is well engineered and dependent on good design rather than digital technology and software.

There needs to be more consideration of medical equipment that has reusable accessories and replacement parts. Equipment used in ICUs was often reusable and came with cleaning instructions. For example, ventilator tubing and pressure transducers were all cleaned and reused.

This type of technology is advantageous in ICUs in low-income countries, as it removes some ongoing costs and reduces the pressure on the supply-chain.

Lowering Device Dependence

Three decades ago equipment such as syringe pumps and volumetric pumps were often limited in number. Critically ill patients simply had less bedside technology.

Since then we have become over-dependent on devices and equipment. There are ways of working that are designed for a relatively device-free existence. Critical care nurses in low-income countries need to utilise prevailing knowledge to learn about their role and devise ways to treat patients without sophisticated equipment.

There are some resources that provide information about this type of nursing. The BASIC collaborative working group has a course for ‘Basic Assessment & Support in Intensive Care – Developing Healthcare Systems for Nurses’.

Putting the Profession on the Map

Previously, critical care nurses in resource-limited settings were often marginalised and disparate. It is a pleasing development that they are forming national organisations and it is hoped that these will offer a platform for specialised training, professional development and networking.

At the third African Federation of Critical Care Nurses in Kampala, Uganda, there were many appeals from speakers and attendees for training and continuous professional development.

Speakers from the audience revealed that they lacked training and skills that are considered essential for a critical care nurses. Moreover, the existing training was ad hoc and rarely technical or machine-specific.

An exciting development within Uganda is the Masters-level course in critical care nursing, which is undertaken at Mbarara University of Science & Technology. The first cohort has recently graduated and will be an important influence on critical care nursing within Uganda.

Tackling the Work

Fortunately, the Ugandan government is committed to expanding the critical care capacity within the country. I am an honorary lecturer for this Masters programme and teach advanced physical assessment at the bedside, in the simulation laboratory and in the classroom.

As part of the PhD process, I have become a self-appointed digital curator of critical care nursing in resource limited environments. I’m currently compiling a database of clinical literature and academic publications that pertain to this nursing speciality. This resource is becoming a collaborative venture and will eventually be available to clinical and academic staff.

In contrast to the complexity of doctoral level study, I am also editing a guide to critical care nursing in resource limited environments. This task was on the back burner until I met Dr Mike Dobson at a recent Diamedica study day.

I was able to learn about anaesthesia in developing countries, as well as receive invaluable information about self-publishing.

The study day was the perfect blend of presentations, demonstrations and learning some technical skills. It provided an opportunity to meet the director of Diamedica and get inside information about their products and expert hands-on training.

Meanwhile, the guide will highlight nursing and critical care practices that are manifest in poor countries and will try to verify their effectiveness. Alternative methods of critical care nursing will be examined.

It is good news that the first publications on critical care nursing in resource limited environments are on the way. Both books are collaborative with contributors from Zambia and Uganda.

There are few resources that provide information about this type of nursing. The forthcoming BASIC collaborative working group have a course for ‘Basic Assessment & Support in Intensive Care – Developing Healthcare Systems for Nurses’ could provide a breakthrough in purpose-designed training.  

Also, Chris Carter, a Major in the QARANC, is currently writing a book on critical care nursing in resource limited environments, that will be published by Routledge in July, 2018.

There is a long way to go to establish a style of nursing that befits critical care units in resource limited environments but 2018 could be a seminal year.

You can reach David on any of the below contacts:

Twitter                 @ltd_resource





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