A Descriptive Study Of Clinical Midwives Experiences Of Covid-19 During Shift Hours In Tamale Teaching Hospital

Abstract

The purpose of this study was to explore the experiences of midwives during the Covid 19 outbreak in Ghana in their shift hours in Tamala Teaching Hospital Ghana. A convenience sample of 110 registered midwives were recruited from the hospital. Using an interview guide, data were collected through face-to-face, semi-structured, and tape-recorded interviews.

The core category identified in the data was “living in fear and terror.” Other categories identified in the data were family, professionalism, God and safety, institutional influences, government efforts, and stigmatization. The work decisions of nurses and midwives were primarily influenced by family responsibilities and demands. The nurses and midwives experienced changes in the dynamics of the nurse-patient relationship and in the nurse-nurse relationship, depending on whether or not they continued working. The findings of this study could be applied to education, practice, research, and health policies related to future disease outbreaks in Ghana and other regions in the world. Nursing curricula should include Covid 19 nursing care. An intervention study could be designed to test modes of safe touch with patients and the ramifications for practice. The role that faith plays in the decisions made by nurses and midwives should be recognized. Administrators and policy makers need to consider the emotional needs associated with the family, isolation, and stigmatization of nurses and midwives when developing measures and policies for Covid 19 containment.

CHAPTER ONE

 

Introduction

1.1 Background of study

In this, the Year of the Midwife and the Nurse, we have again been reminded of the value of quality health care. Health and access to health care are basic human rights, and as the start of 2020 has demonstrated, health care systems around the globe have been challenged by the unprecedented impacts of the COVID-19 virus.

The pandemic has exposed shortfalls of our health care systems but also highlighted the generally unspoken value of health care professionals. Frontline health care workers have not only stepped up to the challenge but have risked their lives in doing so; sadly, many have fallen victim to the virus as a result of their commitment and dedication to health and wellbeing of others. While the focus has largely been on the direct and immediate threat of COVID-19 to the acute health care sector, the impacts on other sectors are now surfacing.

This is true of the provision of maternity care across Ghana as social distancing and restrictions have elicited changes in the way that antenatal and postnatal care are provided but also the level of support that women can access across the full spectrum, most importantly during labour and birth. While the intention and rationale behind these decisions are legitimate – to protect health care workers and the public and therefore reduce potential exposure and transmission of the virus – the changes are proving to be inconsistent, confusing and continuously evolving. Arguably, they are reactive to an everchanging landscape which has not yet allowed for consideration of both the short- and long-term consequences not just on the maternity care workforce, but more importantly, on women, babies and families. In a recent survey, the Ghanaian College of Midwives (ACM) captured the maternity care experiences of nearly 3000 women in Ghana at the height of the COVID-19 pandemic. This report details their responses.

 

A pandemic, as defined by the World Health Organisation (WHO) (2010), is the ‘worldwide spread of a new disease’. While rare, the impacts and consequences of a pandemic are far reaching and have been known to significantly impact the provision of maternity care. SARS and MERS are just two examples. The COVID-19 virus, which is believed to have started in Wuhan, China in late 2019, is a new strain of coronavirus that results in respiratory symptoms ranging from mild to severe.

Transmitted by secretory droplets of an infected person, COVID-19 is a highly infectious disease that spreads rapidly across the population and in the worst cases, can result in morbidity. While the immediate threat of the virus to the community has been a key focus, it is now evident that there will be flow on effects from the acute phase of management and containment. It is acknowledged that there will be implications for the provision of maternity care in the short term and almost certainly ongoing consequences for women, babies and families in the longer term. In response, the Ghanaian Government and jurisdictional health care systems have mobilised to ensure safe, effective and continued service provision with attention to social distancing, infection control and universal precautions to minimise the exposure to and spread of coronavirus through the community. Rapid changes have been embraced by health care providers and other essential workers to maintain high quality service provision.

This has been complemented by messaging that has encouraged people to exercise social distancing measures and to practice high levels of hygiene. This messaging has had an excellent impact in managing the spread of COVID-19. However, as the extent of the pandemic has become clear and changes to the provision of maternity care have surfaced, the ACM received correspondence from concerned midwives, midwifery students and women all who were seeking information and guidance in order to adapt to the rapidly evolving situation. In response, ACM collated information to support these groups, while at the same time recognising the widespread confusion and uncertainty many were feeling particularly as they were receiving mixed messaging. Women who contacted us prior to the development of the survey, expressed significant concern about the possibility of giving birth alone.

This appeared to stem from important social distancing measures that had been put in place in health care facilities, including hospitals for the purposes of keeping all staff and clientele, safe. However, it was evident that the inconsistent information and rapid changes were causing additional anxiety and stress to an already stressful situation. Women also expressed concern with respect to attending a hospital or clinic for fear of being exposed to the virus with this confirmed and echoed by midwives around the country.

 

The recent Covid 19 outbreak in the West African region resulted in many deaths plus devastating health and socioeconomic upheaval. In recent history other regions of the world have been subjected to disease outbreaks such as human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), influenza, and severe acute respiratory syndrome (SARS). As a result there is some awareness of the potential of experiencing disease outbreaks in any part of the world. Health care workers (HCWs) are central to the restoration and maintenance of optimum public health, especially in situations such as disease outbreaks (Barnett et al., 2012). The principles for HCWs’ training and preparedness have been studied to assure their competent handling of these difficult situations. Studies have demonstrated that the adequate training and preparedness of HCWs, including nurses, is key to the survival of the population in the event of a disease outbreak. Typically, HCWs are equipped with skills for surveillance, communication, reporting, and containment of disease outbreaks (Chiu, Polivka, & Stanley, 2011; Qureshi et.al, 2004).

The willingness of HCWs to respond in situations of uncertainty and insecurity, along with their perceptions and attitudes towards their roles during disease outbreaks, influences their availability and positive response to the need for containment of the disease (Barnett et al., 2012; Devnani, 2012).  Influenza epidemics have received attention by scholars and researchers have identified that HCWs were willing to respond or care for the victims during influenza virus epidemics (Balicer et al, 2010; Barnett et al. 2009; Baster, Edwards, & Schulte, 2009).  Studies have indicated differences in the rate of willingness of health workers to care for patients who are victims of virulent and life threatening epidemics, pandemics, and infectious diseases. Barnett et al. (2012) and Basta, Edwards, and Schulte (2009) describe the determinants of HCWs higher willingness to respond to include type of disease outbreak (e.g., less virulent diseases associated with higher willingness), and that lower threat perceptions of health care workers are associated with higher efficacy assertion (meaning higher assertion to being competent to handle the situation) by health care workers. In other words, the less virulent a disease outbreak, the lower the threat perception of the disease outbreak, and the higher the assertion of competence to handle the situation. This in turn promotes a higher willingness of health care workers to respond or care for patients during disease outbreaks. During the peak of a  disease outbreak, frontline health care workers who must  be in very close contact with victims of the outbreak, especially virulent diseases that are of high risk to HCWs, were found to have a high rate of unwillingness to respond  (Barnett et al., 2012; Baster, Edwards, & Schulte, 2009).

Despite what is known about HCW willingness to care in other disease outbreaks, research on the willingness of HCWs to care for victims of Covid 19 has not yet received much attention. The inner experiences of HCWs combating Covid 19 in a region that has never experienced such an epidemic is not yet understood. It is both timely and vital that a study describing the experience of health care workers and their willingness to care for patients during the Covid 19 disease outbreak be conducted. It is also important to identify those factors that influenced HCWs to care for patients during the Covid 19 outbreak.

It should be noted that during the Covid 19 outbreak in Ghana and West Africa as a whole, not only was there a need to care for patients who had contracted the Covid 19 virus, but there were other patient populations who needed other health care services. Pregnant women, women in labor for child birth, and postpartum women, children, and other adults with diverse conditions not related to Covid 19 were constantly in need of health care services.

Coping with a new disease with high mortality within the region, including development of treatment protocols, was a concern in the region. The resources needed including experts and health care workers, who were experienced in treating patients with Covid 19, were not readily available. The cause of this adequacy in Ghana (one of the countries in the region) was that the country had recently emerged from 14 years of civil war which lead to lower availability of health resources and dysfunctional health care systems (Buseh, Stevens, Bromberg, & Kelber, 2020). In addition, Covid 19 virus disease symptoms are not easily differentiated from other endemic diseases like malaria, gastroenteritis, or cholera (World Health Organization [WHO], 2020). The symptoms of Covid 19 virus disease are indistinct from other infectious diseases and fatal. This led to increased anxiety levels of health care workers, such that every patient who sought care or health care services for other health conditions were treated as suspected cases (Hayter, 2020). Furthermore, WHO (2020) released a statement on the Covid 19 outbreak in Ghana in which they stated that Ghana had reported the highest number of deaths in the largest, longest, and most complex outbreak since Covid 19 first emerged in 1976 in the Democratic Republic of Congo. At the peak of the epidemic, which occurred between August and September 2014, the country was reporting from 300 to 400 new cases every week. During those two months, according to WHO (2020), the capital city Monrovia was the setting for some of the most tragic scenes from West Africa’s outbreak. Gates were locked at treatment centers that were overflowing with patients, patients were dying on the hospital premises, and bodies were sometimes not collected for days. Flights in and out of the country were cancelled, and supplies of fuel and food ran low. Public facilities such as schools, businesses, border crossings, markets, and most health facilities were closed. The nation was in fear and uncertainty about the future―for families, for communities, and for the country and its economy. The situation devolved until treatment beds for Covid 19 patients were exhausted and were no longer available anywhere in the country. This led to the abandonment of infectious cases and corpses remaining in homes and communities. Physicians and nurses continued to play a key role in the management and treatment of patients, even when supplies of personal protective equipment and training on its safe use were inadequate. Altogether 375 health care workers were infected and 189 lost their lives (WHO, 2020).

 

1.2 Statement of problem

The International Council of Nurses (ICN), in a 2020 press conference, alluded to the problem the Covid 19 outbreak posed to HCWs within the West African Region and the entire health systems of the countries affected by Covid 19. The ICN (2020) noted that Covid 19 infections were contracted by health care workers, resulting in devastating effects on the health system, including closure of hospitals, depletion of the much-needed health care workforce, and distrust in the health system. According to the ICN (2020), Covid 19 exacerbated the pre-existing shortage of health care workers, high rates of attrition, uneven distribution of workers, poor employment conditions, and gaps in occupational health and safety in the three countries most affected within the West African region:

Guinea, Ghana, and Sierra Leone. The ICN reported that health care workers were 21-32 times more likely to be infected with Covid 19 than were adults in the general population. In the affected countries, nurses accounted for more than 50% of all health care workers infected, physicians and medical students account for 12%, and laboratory workers accounted for 7%. The ICN (2020) recommended that in light of the numbers of nurses who lost their lives, there is need to strengthen safety policies, and provide adequate protection and appropriate training. In addition, the ICN, issued a declaration which called on governments to create safe working environments for health care workers as a prerequisite to the provision of care to Covid 19 patients; it also called for adequate training and education, availability of protective equipment, as well as nurses taking an active role in policy making regarding the prevention of infection and patient care.

With the high risk to nurses associated with caring for infected patients, there is a need to explore the experiences of nurses and midwives during the Covid 19 outbreak in Ghana, to gain their perspective on the safety issues, which social processes influenced the situation, and what other measures apart from safety assurance would be needed to develop a more realistic policy that will meet the needs of nurses and other health care workers. There is also the need for a holistic and comprehensive approach to understand what HCWs, specifically nurses and midwives went through during the epidemic while caring for Covid 19 and non-Covid 19 patients. It is important to explore the social process involved in nurses’ and midwives’ decision making about rendering or not rendering care to patients during the Covid 19 outbreak.  We need to understand why those nurses and midwives who continued to care for patients did so, and the decision making of those who chose not to work during the Covid 19 outbreak. We also need to explore how nurses’ and midwives’ willingness to care for patients during the Covid 19 outbreak influenced the care for patients who had contracted Covid 19 virus, as well as other patients with other life threatening conditions.

1.3 Objectives of the Study

The purpose of this study was to explore the experiences of nurses and midwives, including the decision making process involved in caring for patients during the Covid 19 outbreak in Ghana.

Specific Objectives of the Study

The specific aims of this study were to:

1. To describe the experiences of nurses and midwives during the Covid 19 outbreak in Ghana.
2. To analyse the work decision process used by nurses and midwives during the Covid 19 outbreak in Ghana.
3. To determine the level of effectiveness of maternity operations by midwives during the Covid 19.

1. What are the experiences of nurses and midwives during the Covid 19 outbreak in Ghana?
2. What are the work decision process used by nurses and midwives during the Covid 19 outbreak in Ghana?
3. What is the level of effectiveness of maternity operations by midwives during the Covid 19??

 

1.5 Research hypothesis

H0: There is no significant implication of Covid 19 pandemic on maternity care in Tamale Teaching Hospital

H0: Midwives’ experiences during the Covid 19 pandemic did not alter their regular maternity care techniques

1.6 Significance of the Study

This study provides a description and interpretation of the experiences of nurses and midwives who in the face of grave danger chose not to continue to care or who continued to care for both Covid 19 and non-Covid 19 patients during the Covid 19 outbreak. The study showcases the contributions and reasons for the work decisions of nurses and midwives during the Covid 19 outbreak. The outcome of the analysis describes and interprets the experiences of nurses and midwives, the characteristics of the nurse-patient relationship, and the characteristics of the nurse-nurse relationship during the Covid 19 outbreak.  The outcome of the analysis also provides a conceptual model that explains the personal, institutional, and governmental influences involved in the process of nurses and midwives deciding whether or not to continue providing care. The findings are informative for practice, policy decisions, education, and curriculum development of nurses and midwives on Covid 19 nursing care. The findings may also lead to further research on Covid 19 outbreak management in the studied location and other locations with similar contextual or socio-cultural conditions.

The stories of the nurses and midwives offer understanding into their experiences in the midst of life-threatening circumstances during the Covid 19 outbreak. From the perspectives of the nurses and midwives who were involved in the care of patients during the Covid 19 virus disease outbreak, other nurses, midwives, and HCWs may gain insight into the personal, institutional, professional, and government influences on their attitudes and practice. This understanding might be useful for those who will face similar circumstances in the future. These findings have implications for practice protocols regarding the personal preparedness activities, nurse-patient relationship, nurse-nurse relationship, and protective measures of nurses and midwives in the event of a Covid 19 outbreak in Ghana, and other resource-challenged areas of the world.

1.7 Limitations of the Study

The participants in this study were mostly female so the findings indicated from the data may not reflect the male perspective. The participants were midwives in Tamale Teaching Hospital, Ghana; complete representation of the experiences of nurses and midwives in the rural areas may therefore be lacking. The interviewing skills of the researcher improved as the interviews progressed; therefore, earlier interviews might not have captured the level of depth as those that followed. However, interviews were conducted until data saturation was achieved.

 

1.8 Definitions of Terminology

The operational terms used in this study are subjective values and in the context of this study are defined as follows:

COVID-19: a disease caused by a new strain of coronavirus. ‘CO’ stands for corona, ‘VI’ for virus, and ‘D’ for disease

Experiences: the process of personally observing, encountering, and/or carrying out patient nursing care and/or midwifery care activities over a course of time.

Midwives: certified and registered health care personnel who have at least three years training in midwifery. In addition to their certification, some

have a bachelor’s degree in nursing. Midwives work in the obstetrics and gynecology units, labor and delivery wards, and postnatal clinics.

Nurses: are certified and registered health personnel who have completed at least three years training in a nursing program at the diploma level. In addition to their nursing diploma, some have also earned a bachelor’s degree in nursing. Nurses are in almost all care units or wards in the hospital.

 

Work decision: are the influences and outcomes of choices made by the nurses and midwives to decide whether or not to continue caring for patients during the Covid 19 outbreak.

 

1.9 Organization of the study

Chapter one introduces the research, the aim, significance and scope of study, Chapter two includes a critical review of quantitative and qualitative studies conducted on disease outbreaks and health care workers’ responses and attitude towards them. Sensitizing frameworks for this study are also described in chapter two. Chapter three addresses the research design and methods for this study, and also includes the sampling plan and setting for this study, the method of data collection, the process and procedure for collection of data, and the method of data analysis used. Chapter four includes the description of the findings from the data analysis.  Chapter five provides the discussion of the findings and highlights the recommendations and conclusion of the study.

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