NNASA will be hosting its 9th National Neonatal Nurses Conference from 3-4 June 2020 at the Wanderer’s club in Johannesburg-Yes we are finally coming to Gauteng again! On the Gautrain bus route and with plentiful accommodation options in the area there is no excuse not to come.

The conference theme is Purposeful Passion and you don’t want to miss this one as we are doing things a little differently this year …. Following our usual 2 full conference days we are hosting an all day trade exhibition. This will be open to all health professionals working with neonates. Picture workshops, presentations, food stalls and lots of networking!

So start planning today! Send your abstracts to info@nnasa.org.za. We look forward to seeing you there.

It’s World Breastfeeding Week celebrating “Empower Parents: Enable Breastfeeding “No matter who you are – you can join the conversation or take action to encourage, promote, support and protect  the mothers right to breastfeed her baby for  better  growth, health and development.

South Africa has come far from a breast feeding rate of 8% in 2003 to 32% in 2016 but still falls far short of the global target of a 50% breastfeeding rate in the 1st 6 months.

Click below to find out more about how breast feeding can benefit both mother and baby.

https://www.healthline.com/nutrition/11-benefits-of-breastfeeding

This World Breastfeeding Week, take the pledge, join the conversation and action to encourage, promote, support and protect the rights of women to breastfeed. You can do this by making a statement on social media or sharing your activity or community initiatives in support of breastfeeding for a greater impact. For more information click below.

https://sidebyside.co.za/

#WeBreastfeed #WBW2019ZA#BreastfeedingDialogues #sidebysideSA

In May, NNASA was proudly represented by Carin Marais and Ruth Davidge who both presented at the 10th International Neonatal Nurses Conference in Auckland, New Zealand. As members of NNASA part of your membership fee goes to COINN and NNASA members are therefore members of COINN and currently represented on the COINN board by Carin.

Before the conference officially opened delegates had the opportunity to attend workshops one of which included a unit tour of Starship Children’s Hospital’s Neontal unit and the head quarters of Fisher and Paykel. What a privilege to visit such a beautiful unit! The thought and particularly the nursing input that had gone into its design were evident. There was a wonderful mix of technology, space and family and staff areas. Visiting Fisher and Paykel was also an incredible experience. To see the stringent quality control systems that are in place and the very organized work spaces (even to tape on the floor demarcating where the waste bin should go!) was incredibly comforting to a very OCD neonatal nurses brain.

The opening ceremony included a wonderful cultural Maori ceremony. This theme of being culturally thoughtful, relevant and inclusive was evident throughout the conference. It was followed by an excellent speech by COINN president Carole Kenner focussing on the role neonatal nurses need to play in advocating strongly at every level for the needs of neonate. It was followed by the presentation of Neonatal Nursing Excellence awards. The cocktail party was a wonderful opportunity to renew old friendships, make new acquaintances, explore the large trade exhibition of 36 stalls and generally let your hair down.

The conference theme was Enriched Family-Enhanced Care and delegates were inspired on the first day by presentations from Heidelise Als, the 80 year old doctor, who first introduced the world to the idea of individualized developmentally supportive neonatal care through the NIDCAP program. This was a fitting start to the conference that constantly reinforced the important role of families and the need to integrate them into every level of care including drafting guidelines and research. This was very relevant as we are considering an expanded role for mothers in South Africa to empower them to observe their own babies. It was also reassuring to see that every country in its own way has challenges to overcome. A presentation from China was fascinating as they shared their struggle to introduce KMC in the face of traditional beliefs that the mother cannot leave her room for the first month after birth. There were also in depth breakfast sessions on skin care and feeding guidelines. It really was inspiring to hear the influence neonatal nurses can have to change practices in their units and countries when they have knowledge, experience, passion and confidence to step out and speak up!

The gala dinner was a splendid affair organized and decorated by the Starship neonatal unit staff. All the delegates went to great effort to dress according to the Gatsby theme. The delegates were given a wonderful history lesson about the start of neonatal intensive care which began during this period of the 1920s as an entertainment exhibit at Coney Island. We also had a moving dance tribute from your dancers many of whom were ex prems saying thank you for the care neonatal nurses give. We left feeling motivated, inspired, challenged, energized and sad to say goodbye to our like minded global family. See you in 20121 in Aalborg, Denmark!

For the past 19 years I have been lecturing to the 4th Year Medical Students regarding the care of the most vulnerable of all patients….the preterm baby.

What do you need to let a Dream come TRUE???…..A dreamer.

One amazing young student, Johane Potgieter who understood the risks of Hypothermia for these little ones.

In her own words  ” I had the privilege of meeting these tiny miracles who came through the doors of the NICU. Their fighting spirits inspired me to reach out and make a difference.”

She saw the need… and realised that many of the moms do not have the means to provide their preterm infant with beanies and socks

And this was the birth of The Beanies4Babies Project

Their dream

Their dream is to provide comfort and support to approximately 150 premature infants admitted to Pelonomi and Universitas’s NICU by providing each infant with his or her own pair of knitted socks and a beanie. This gift is given to them as soon as they arrive in the NICU and are theirs to keep when they are discharged.  

These girls rely solely rely on donations, whether financial, wool or hands to knit, and are always in need of more donations, either financially or product (wool).

The vision is to expand their dream and relieve the burden nationwide in the NICU’s of South African state hospitals.

This initiative has now expanded to Dora Ngiza in Port Elizabeth…..which hospital will be next???

How can I get involved???

  • Start knitting!!!
  • Or donate 4-thread wool (baby) and Nr 4 knitting needles.
  • Or get grandma’s in Old age home’s in your hospital area involved, to become part of a much bigger picture. Knitting is a sure cure for boredness and depression.
  • Financial support.

Banking details:     

MACAH Foundation NPC Nedbank Br: 198-765 Acc: 114-270-2030 Ref: B4B Name or Company name  

PLEASE send proof of payment to: debruintr@ufs.ac.za or 2013004631@ufs4life.ac.za

We look forward to your involvement and willingness to be part of our caring project.

Contact details:

Project Leader Project Leader MACAH F Coordinator
Johane Potgieter 076 392 5658 Clarette Cronje 076 975 4969 Tertia de Bruin 082 808 6099

NNASA together with SOMSA, NEA as well as Consultants from paediatrics and dermatology at UCT formed the working groups that drafted the 1st South African Neonatal Skin Care Guideline.

The aim of this skin care guideline is to provide evidence based, contextualized guidelines for the care of full term, healthy neonatal skin.

Complications in skin conditions and special populations, such as preterm and critically ill infants are outside the scope of this document. 

This document is based on the third edition of the AWHONN Neonatal Skin Care Guidelines, however all sources and recommendations were checked by the working groups, updated and contextualized for the South African context. This was done with permission of AWHONN following a presentation by AWHONN representatives at a consultative meeting in April 2017 where the AWHONN Neonatal Skincare Guidelines were launched.

Topics discussed :

  • A. Vernix caseosa 
  • B. Cord care
  • C. Bathing
  • D. Buttock Care
  • E. Neonatal Male Circumcision  
  • F. Disinfectant
  • G. Emolients
  • H. Medical Adhesives.

A. Vernix caseosa recommendations:

  • Do not remove vernix caseosa from newborn skin. 
  • Even when blood, meconium or faeces have to be removed, it should be done gently to protect the vernix, since vernix protects the infant against infection, decreases in skin permeability and Trans Epidermal Water Loss (TEWL), cleanses and moisturises the skin, protects the acid mantel, acts as epidermal barrier, aids skin rejuvenation and contributes to temperature control.

B. Cord care recommendations:

  • Ensure a clean birth
  • Apply 4% chlorhexidine gluconate as a single application following birth to the cord.
  • Use cooled-down, boiled water or breastmilk to clean the cord with each nappy change (natural drying).
  • The cord may be submerged when the infant is bathed and washed with water and soap when soiled.
  • Keep the cord uncovered/lightly covered and dry until separated.
  • In case of infection, treat the infection systemically.
  • Prolonged and routine cleaning with surgical spirits is not recommended.

C. Bathing recommendations:

  • Delay the first bath for 6 – 24 hours until the infant is physiologically stable and do not remove the vernix.  The exception would be the neonate excposed to HIV, who would need an early bath as part of infection control.
  • Bath the infant in such a way as to prevent heat loss and stress; immersion bathing and swaddle bathing are both acceptable.
  • Use a mild, nonirritant cleanser and regulate the bathwater temperature at 37-37,5 degrees Celcius.
  • Potential irritants such as chlorhexidine gluconate are not recommended for whole body use.

D. Buttock care recommendations:

  • Clean the nappy area whenever wet or soiled, with mild cleanser or soap or baby wet wipes to gently wipe the perineum and buttock area from anterior to posterior.
  • Dry the skin gently and apply a protective cream containing zinc oxide or petroleum jelly.
  • Change nappies when wet or soiled and encourage breastfeeding.
  • Treat Candida albicans with antifungal ointment or cream, and with systemic antifungals if very resistant.
  • Do not use talcum powder or corn starch.

E. Neonatal Male Circumcision recommendations:

  • Neonatal male circumcision should only be performed by skilled practitioners, in healthcare settings with good infection control measures.
  • The penis should be cleansed with cooled, boiled or sterile water only for the first 3-4 days and petroleum jelly applied to the raw areas.
  • No lubricants and dressings should be used when plastic circumcision devices were used.

F. Disinfectants recommendations:

  • Clean newborn skin with the best available product, considering potential toxicity and potential skin irritations or burns.
  • 4% chlorhexidine gluconate and 10% povidine iodine are generally less irritant than isopropyl alcohol.
  • Consider the application techniques and remove all disinfectants after the procedure with sterile water or saline.

G. Emollients recommendations:

  • Appropriate emollients should be applied routinely to newborn skin without friction and specifically at the first sign of dryness or in those with a family history of eczema.
  • Olive and sunflower oil are not routinely recommended to treat dry skin conditions.
  • Until further research is conducted, caution should be exercised when recommending oils for neonatal skin (Cooke et al., 2016: I).
  • Emollients should not be used when infants are receiving phototherapy.

H. Medical Adhesives recommendations:

  • Routine use of skin barrier protective films and avoidance of direct tape to skin contact lowers the rate of epidermal stripping.
  • Medical adhesives should be selected to cause the least tissue trauma, yet effectively securing medical devices.  
  • Medical adhesives should be removed slowly, pulling on a horizontal plane, using moistened gauze.
  • Mineral oil or petrolatum can also be used to loosen tape. 
  • Application should be avoided whenever possible and the following products should be avoided: alcohol/organic-based products, oil-based solvents, enhancing bonding agents and adhesive bandages after venepuncture. 

Research Round up.

Dr Vicky Culling presented at the Gold Neonatal 2019 On-line Conference on providing care and support when a baby dies in the NICU.  Her core message related to the fact that grief is about love and love never ends. Therefore, there is no time limit on how long one should grieve. Grief is also unique to every situation and to every affected person. We should be mindful to how we handle such situation and we should choose our words carefully. A quote by Brené Brown states that rarely a response makes something better – what makes something better is connection.   The only things we should do in terms of support is to acknowledge, validate and connect.  During her talk Dr Vicky Culling recommended the following links in relation to providing care and support when a baby dies in the NICU.

https://www.psychologytoday.com/intl/blog/laugh-cry-live/201902/should-parents-moveafter-their-baby-dies

https://www.psychologytoday.com/intl/blog/laugh-cry-live/201810/10-tips-offering-realcomfort-people-in-crisis

https://www.psychologytoday.com/intl/blog/laugh-cry-live/201704/mindful-approachsupporting-bereaved-parents

https://www.psychologytoday.com/intl/blog/laugh-cry-live/201309/when-baby-dies-pickingthe-pieces

https://www.psychologytoday.com/intl/blog/laugh-cry-live/201309/coping-guilt-after-yourbaby-dies

Over the last few years in SA, the dramatic rise in neonatal litigation has highlighted the need for improved clinical record keeping. While it is critical that there is accountability within the health system when errors do occur, in many cases the health care provider or institution is unable to defend the care given due to the poor quality of the clinical records. The generally accepted rule is that “If it isn’t recorded-it wasn’t done”

Some common errors in record keeping include:

  1. Illegible  handwriting
  2. Lack of dates, times and signatures
  3. Incomplete, scanty or missing documentation
  4. Subjective rather than just factual entries
  5. Use of abbreviations
  6. Lack of documentation regarding medication or treatment that wasn’t given
  7. Not questioning illegible entries or orders
  8. Entering data on the wrong chart
  9. Adding entries out of chronological order

As I travel and visit many different neonatal units I am frequently struck by the volume of nursing entries and the often scanty medical entries. The challenge I find is with what is recorded by the nurses.

An entry might read: Mother reports baby is doing well. Observations: T= 36.7⁰C, Pulse= 134 bpm, Resp= 56 bpm, Saturations= 92%. Assessment: Baby is stable. Continue with management

As you can see this doesn’t provide much insight or information that can’t be found elsewhere in the clinical record and really adds no value. A more comprehensive systems based assessment is required but this can often be long winded and time consuming.

Observations are generally comprehensively completed at the required times but it is apparent that nurses are not thinking about what they are recording. The Nursing Process appears to be an abstract concept they learnt about years ago in college not a living process to guide their care.

Assessment. Nursing Diagnosis. Planning. Implementing. Evaluating. Each step needs to be completed before we can progress further in the process.

When a nurse observes/assesses her patient the goal should be to detect a problem, make a plan about what to about it, implement the plan-take action and then reevaluate to assess whether the action was effective. Unfortunately in many cases the nurses appear to stop after the first step. They document observations. There is no identification of abnormal observations or the problem found, no action is taken and the observations are only repeated again at the routine time. It appears as if the goal is to have a beautifully completed record not to document the condition of the patient and interventions given.

This negatively impacts on care and outcomes. Commonly hypothermia is not detected or acted upon. Research has proved for every 1C drop in temperature below 36⁰C- sepsis risk increases by 11% & mortality risk increases by 28%   (T. Cordaro et al 2012.)

Likewise saturation and oxygen levels are well documented but no action is taken particularly for high saturation levels in the presence of oxygen. This immediately increases the risk of Retinopathy of Prematurity and the possibility of resultant litigation.

These are the basics of nursing care and do not require an advanced diploma or degree in order to implement.

In KZN, after a lengthy process of review and consultation, a new set of standardized neonatal records have been produced. These records have attempted to reimagine how a clinical record looks and functions.

In developing the records the following objectives were considered- the records must:

  1. Be neonatal specific
  2. Be comprehensive and accurate
  3. Be accessible and attributable
  4. Be appropriate for level of care (Hospital/Bed)
  5. Reduce the time taken in recording
  6. Improve the quality of what is recorded
  7. Support improved quality of clinical care rendered
  8. Facilitate multidisciplinary recording.

The new records include the following changes:

As with any new record –it is only as good as the person completing it. A record can only support provision of quality care, not guarantee that it is delivered! It is therefore crucial that, when aiming to improve record keeping, there is effective and frequent supervision and mentoring from leaders and monthly structured auditing of the records. In KZN this auditing process includes both the quality of the record and the quality of the care recorded (a clinical audit). A minimum of 5 records are audited every month. This audit process must include both nurses and doctors.

With the chronic nursing shortage in most units there was initially skepticism and resistance to the introduction of these records with units stating they are too long & of too high a standard, but following thorough orientation and increased familiarity hospitals report satisfaction with the tools. The process of rolling out these records is still underway. Buy in is better at level 1 hospitals where there are smaller teams. Some doctors at level 2 hospitals object to the structured format and prompts and yet their records are historically poor. Correct use of the records is still poor with some users just leaving out parts of the tool with which they are unfamiliar. Ongoing support and guidance will be required to assist facilities with implementation. Implementation of the monthly record/clinical audits and ongoing mentoring will raise awareness of what is required and support monitoring of compliance. Only time will tell, but hopefully this will sustainably improve quality of clinical care and recording.

So I challenge you to assess the records in use in your units and to ask:

  • Do they meet the objectives stated above?
  • Is your unit conducting frequent, structured, multidisciplinary record audits?
  • Are you proud of your records-do they reflect the standard of care you want for your patients?
  • Is it time for a change?

A seminar was hosted by the UCT Division of Nursing and NNASA on 13th September. The focus included some revision and reminders of aspects of the Respiratory System. Topics included embryology and physiology of the respiratory system, Surfactant, adaptation to extrauterine life, humidification, ventilation modes, PPHN and after lunch, skills workshops of neonatal resuscitation, passing an umbilical line and a presentation on prevention of Central Line Infections.

Fifty-five nurses from State and Private hospitals attended from around Cape Town and as far afield as Worcester and Paarl. Feedback indicated that this was a very beneficial seminar and suggestions for another one have been noted.

On 27 November a seminar will be held at Stellenbosch University with joint hosts being the Tygerberg Children’s Hospital (TCH), University of Stellenbosch (US) and NNASA. This seminar will focus on Head cooling and management of HIE. Over 300 delegates have registered and we are expecting a wonderful information-packed morning of learning, experiencing and networking!

For 2019, we are planning to present another UCT hosted seminar and hopefully, another joint TCH, US and NNASA seminar.

Hilary Barlow
November 2018

The other day, during a visit to a local public sector hospital I noticed that a baby’s saturations were 100%. The baby was receiving blended nasal prong oxygen. The alarms on the monitor were not set. This is a common finding and of major concern not only for all the babies who are being placed at risk of retinopathy of prematurity (ROP) but also for our institutions due to the high prevalence of litigation particularly for ROP.

I swung into action teaching on why it was so important to set monitor alarms accurately, the problems of alarm fatigue, the risk of retinopathy and the crucial role of nurses in managing oxygen therapy and in particular weaning oxygen according to saturations. While teaching I demonstrated setting the alarms and weaned the oxygen until the baby was in room air. At that point the doctors arrived to do a teaching round and the consultant was most unimpressed that I had weaned the oxygen stating that the baby had a history of apnoea. I wont go in to the discussion that arose thereafter but the nurses later informed that they were not allowed to wean oxygen without a doctors order and had been instructed to set all blenders at 40% regardless of saturations.

As you can imagine I was angry and concerned at the situation, as I believe it placed the babies at risk and undermined the nurses independent function and their obligation as patient advocates to deliver and advocate for the best possible care. As nurses we are responsible to constantly update our knowledge and to deliver care that is in line with the latest best practice/standards/evidence. But what is the point if we must just blindly follow doctors’ orders.

This question reminded me of an old paper I had read by our own Charlotte Searle- The Dependent, Independent And Interdependent Functions Of The Nurse Practitioner — A Legal And Ethical Perspective -presented at the 1st International Congress on Nursing Law and Ethics which took place in Jerusalem, Israel, June 13-17, 1982.
https://pdfs.semanticscholar.org/5a10/605431a34a758a437ac825050243cb2ba568.pdf
I encourage you to read the whole article-its only 5 pages;-)

In the paper she explores the 3 different functions of nurses and how these have evolved through history including possibly the first recorded incidence of a midwife refusing to carry out an order when midwives Siphra and Pua disregarded the order of Pharaoh to kill all the newborn male infants born to the people of Israel. (Exodus 1: 15-21)

I quote:
“The dependent function of the nurse is based on the law which authorizes his/her practice, as well as on common law and relevant statutory laws. This includes the regulations made by the subsidiary legislative authority, namely the South African Nursing Council. It further includes decisions given by the courts and the interpretation of such laws.
It is not based on that which the doctor prescribes requests or directs for the patient. The registered nurse should still act as a professional person and should be responsible and accountable for her own acts and omissions even in accepting such direction or prescription.”

“The interdependent function relates to the inter-relationship of the nurse with the patient and with other members of the health team. In particular it relates to the interdependence of nursing and medicine. The nurse, whether as institutional practitioner or as private contractor, is not the servant or subordinate of the doctor. She is a registered nurse practitioner, entirely responsible and accountable for her own acts and omissions to the registration authority, the South African Nursing Council, and in the broader sense, to the courts. Where she accepts a prescription, request or direction for treatment of a patient from a doctor, she does so as an independent practitioner on behalf of her patient and as a shared responsibility with the doctor.”

“The independent function of the nurse has two dimensions. One dimension relates to all those aspects inherent in nursing diagnosis, treatment and care which are the normal prerogatives of the nurse. The other dimension is concerned with the manner in which she carries out any of her duties as a registered nurse, whether this be an independent or interdependent function. Whatever she does, she does on her own responsibility and accountability for in law she is personally liable for her acts of omission or commission. She and she alone remains accountable for her actions.”

As can be seen it’s quite a complex and sometimes rather a murky situation.

When considering how a nurse should react to orders she thought were wrong I was reminded of the Nuremburg trials following the Second World War. A set of principles were developed following these trials to determine what could be considered a war crime. These have implications for soldiers and, as modern nursing evolved from a military background, (Florence Nightingale served in a military hospital in the Crimean War and doctors were senior military officers) for nurses as well.

“According to the Nuremberg Principles, it is not only the right, but also the duty of individuals to make moral and legal judgments concerning wars in which they are asked to fight (or orders they must carry out). If a soldier participates in an illegal war (and all wars, apart from actions of the UN Security Council, are now illegal) then the soldier is liable to prosecution for violating international law. The fact that he or she was acting under orders is not an excuse. The training of soldiers is designed to remove the burdens of moral and legal responsibility from a soldier’s individual shoulders; but the Nuremberg Principles put these burdens squarely back where they belong – on the shoulders of the individual.”
The Nuremberg Principles and Individual Responsibility- John Scales Avery

Before we carry out any orders we have an obligation to determine the moral, ethical and legal validity of the order. This can be difficult for an average nurse to do and we therefore rely on facility/institutional/ provincial or national guidelines and policies to guide our practice, but we are still responsible and accountable for all our acts and omissions.

I came across this article “Greater nurse autonomy associated with lower mortality and failure to rescue rates.”
(Van Oostveen C, Vermeulen H, Evidence-Based Nursing 2017;20:56.) in which the authors investigate the value of nurses’ clinical knowledge in decision-making for improving patient outcomes.

They found that patients receiving care within hospitals that promote nurse autonomy have 19% lower odds of death within 30 days and 17% lower odds of complications leading to death within 30 days.

“This study provides evidence that when nurses do not have the ability to exercise their clinical and organisational knowledge, patient safety is put at risk. Therefore, healthcare organisations are responsible for providing necessary means for nurses to act autonomously, that is, by formulating clear roles, responsibilities and behaviours; enhancing competence in practice and decision-making; using shared governance organisational structures, and by creating strong visible leadership. However, nurses should also take responsibility for their own behaviours and actions. ‘To optimise its value, autonomy must be accompanied by proactive behaviour (ie, self-starting and forward thinking to prevent, rather than react to, workplace problems) on the part of nurses’”

Most nurses today have a wonderfully affirming, mutually respectful and supportive relationship with their medical colleagues and do play a vital and integral role in delivering quality clinical care however, as can be seen in the example at the beginning, this is not the experience of all. It is crucial that we understand and operate fully in all three aspects of our nursing functions, that we claim our professional status and embrace our key responsibility to always advocate for the best possible care. In order to function in these roles it is critical that we continue to learn and develop and to stay current with research in order to develop confidence and clinical credibility.

Take pride in being a nurse and stand up for yourself as a professional with a vital role in the multidisciplinary team. Your babies and their families are depending on you!

Most mothers whose babies have been discharged from the NICU struggle to reconcile with what should have been one of the happiest moments of their lives i.e. the joy of a new baby with that of trauma, resuscitation, life support equipment, strings ad gadgets attached to their baby and many other terrifying experiences.

These mothers need a great support to be able to take care of their babies at home independently. This process of discharge should be started early in order to address all fears and misconceptions that she might have before going home. All questions and fears must be addressed professionally, and parents should not be made to feel that they are asking any stupid question and that will make them to be free to ask any question.

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