Training Visit Report 2009

 

St Mary’s Hospital, Isle of Wight (UK) – Juba Teaching Hospital 

(South Sudan) Link

 

 

REPORT OF TRAINERS’ VISIT TO JUBA
TEACHING HOSPITAL, SOUTHERN SUDAN

17th March 2009 – 3rd April 2009

i) A visit to Juba Teaching Hospital was undertaken by four members of the St Mary’s, Isle of Wight (UK) – Juba Link from the 17th March 2009 to the 3rd April 2009 by Eluzai Hakim (Physician), Fiona Henderson (Anaesthetic Specialist, Noreen Collins (Registered Nurse/Midwife with tropical diseases training) and Sharon Evemy (Intensive Care Unit Nurse with experience in stroke medicine).

ii) The Team was joined by Mr Mayen Achiek, Senior Specialist in colorectal surgery at Kings College Hospital, Denmark Hill in London in the first fortnight. of the visit. Mr Achiek carried out an independent assessment of the Hospital facilities.

iii) The team brief was to train medical officers (equivalent to FY2 or ST doctors in the UK), anaesthetic assistants, theatre nurses and general nurses. The Team sought to find out aspects of training not covered by the previous teams to inform the training strategy of subsequent visiting teams. No anaesthetists from the Link have ever visited Juba Teaching Hospital (JTH). Dr. Fiona Henderson, Anaesthetic Specialist, worked in the theatres, established the magnitude of the training needs, carried out targeted training sessions and made recommendations for future development. The nursing needs were enormous, ranging from absence of teamwork with other healthcare professionals, lack of patient care plans, shortage of drug and fluid charts, difficulty in obtaining photocopies of forms needed in everyday nursing work, poor practice in recording vital clinical signs, lack of a system of procuring supplies for the wards to lack of Nursing uniform to distinguish nurses from patients or relatives. Noreen Collins’ and Sharon Evemy’s efforts in trying to rectify some of the aforementioned nursing problems are contained in the nursing section of this report.

iv) Eluzai Hakim went on ward rounds with Dr Emmanuel Jermano Boyong, the Head of Department of Medicine, attended medical referral clinics, had a four hour meeting with the Consultants, addressed all the medical officers (trainees) on the value of training and how to progress their careers at JTH through commitment to lifelong learning with the help of the Link, discussed arrangements for the establishment of the School of Nursing and Midwifery with relevant Ministry of Health officials and explored the extent of monetary support the Ministry of Health is able to contribute towards the construction of the Link House in Juba.

v) This Report is a joint effort of the Members of the training Team. Any opinions expressed in the various Sections of the Report are those of the respective authors and do not necessarily reflect the views or opinions of the St.Mary’s, Isle of Wight(UK)-Juba Teaching Hospital Link Core Group

As well as report, the following is intended to give those anaesthetists interested in joining the Link and acting as trainers, an idea of the existing service.

Anaesthesia for Elective and Emergency Surgery

Anaesthetic Assistants provide the anaesthetic service for all elective and emergency surgery at Juba Teaching Hospital – 24 hours a day, 7 days a week . Most have been trained in Khartoum and many are ex-nurses.
Each assistant works a rostered 6 day week, consisting of morning, afternoon or night shifts. There is a minimum of one assistant present for the afternoon and night shift.
Six or seven assistants are present for the morning shift.  Thus, the majority of anaesthetic cover is present between 08.00 and 14.00hrs when the elective surgery is performed :

Monday – Obstetrics and Gynaecology Theatre 1
Tuesday – General Surgery / Orthopaedics Theatre 2
Thursday – General Surgery / Orthopaedics Theatre 2
Friday – Obstetrics and Gynaecology Theatre 1

A third theatre is used for Orthopaedic Trauma / ‘dirty’ procedures
A ‘communication’ book is completed at the end of each shift such that the following member of staff is aware of any potential problems or of any equipment that has been ‘borrowed’ by other parts of the hospital.

Pre-Operative
There is a designated waiting room for patients (of all ages) prior to their operation.
Routine pre-operative investigations consist of Haemoglobin and malarial status.
If cross-matched blood is required then relatives are screened as potential donors.

Recovery Ward
There is a designated room with six beds allocated for this purpose.
The majority of patients, however, leave the theatre premises immediately following the end of their operation and are returned to the ward accompanied by a member of the theatre personnel and/or their relative(s).

Obstetrics
High maternal and perinatal mortality rates are reported. (true figures unknown). Large catchment area is of approximately 150km radius from Juba town centre.
NO obstetric analgesia is provided . There is no anaesthetic presence on the Labour ward and the labour ward theatre is unused.  Emergency and elective caesarean sections performed in Theatre One in the main theatre block.

Paediatrics
No special concessions made for this age group.
Intensive Care / High Dependency Care
At present, there is no functioning ITU / HDU. Juba Teaching Hospital are keen to develop such a facility. However, staff training (and numbers) will be necessary before this can be realized.

Acute and Chronic Pain
Poorly managed. This is partly due to a lack of availability of appropriate drugs.
However, training and education in the control of pain is needed.

Drugs and Equipment
Limited and unreliable supply.
Although the main theatre block has been refurbished in 2008, the use of inhalational anaesthesia techniques is limited as there is no scavenging.
Storage facilities are poorly organised and utilised.
General hygiene could be improved.
(variable supply of anaesthetic equipment means re-use is common)

Anaesthetic Techniques
Predominantly:
• Ketamine with Diazepam for General Anaesthesia
• and/or intrathecal plain 0.5% Bupivacaine for Regional Anaesthesia
Airway management would be considered inadequate by U.K. standards. For example, no intubation at caesarean section and rarely for laparotomy under general anaesthesia.
Post-operative analgesia is poorly addressed

No Gastrointestinal (GI) prophylaxis for obstetric (or other high risk) patients.
No lateral tilt is used during LSCS.
There were two occasions during my stay when the Assistant felt unable to perform the anaesthesia necessary for an operation.
The depth of background knowledge (in basic sciences and disease) and clinical experience that the Anaesthetic Assistants possess, inevitably, do not equate with that of a doctor who has further training as an anaesthetist. However, their work cannot take account of this as there are no medically trained Anaesthetists in Southern Sudan.

SHORT TERM ACTIONS IMPLEMENTED
THEATRES
• Encouraged general cleanliness and tidiness of the workplace (particularly sharps)
• Encouraged organisation and storage of drugs and equipment
• Encouraged stock-taking to allow accurate and timely re-ordering
• TRAINING – this was essentially ‘hands on’ with the anaesthetic assistants during their routine and emergency work. Airway management and the concept of the importance of monitoring and recording observations to manage and anticipate safe anaesthesia was emphasised.
• ANALGESIA e.g. Local anaesthetic infiltration / nerve block by the surgeon was suggested as a useful adjuvant to other analgesic drugs and routes of administration
• An afternoon training session ‘outside’ the theatre environment with the anaesthetic assistants for practice airway management.
‘ANAESTHETIC NOTES’ BOOKLET
• I produced a small booklet for the anaesthetic assistants to keep on them
whilst at work, to aid provision of safe anaesthesia and effective analgesia for patients
RECOVERY WARD
• Equipped with monitor and suction. Self –inflating bag and mask made available in room
• No spare Oxygen concentrator available for Recovery Ward at present
• Suggestion that an Assistant be present with the unconscious patient is mandatory (meeting with Dario Lado, Director General, Juba Teaching Hospital)
• Layout altered to facilitate attending nurse/ anaesthetic assistant
• Introduction of concept of monitoring and recording of observations during emergence and recovery from anaesthesia
• Left lateral position until awake for all patients unless specific contra-indication
PAEDIATRICS
• Pre-medication with Atropine if the child is cannulated in advance of surgery under general anaesthesia with Ketamine
• All children must be weighed to allow calculation of drug doses and fluids
OBSTETRICS
• Use of Left lateral tilt during in all cases of caesarean section until delivery of baby
• Use of 0.5% Heavy Bupivacaine for caesarean section rather than Ketamine

Identification of the High Risk Obstetric Patient
(in consultation with Dr Mirghani, Consultant Obstetrician & Gynaecologist and Jamelia Sake, Senior Midwife).
• To be identified when first seen in clinic and on admission to labour ward.
• Obstetric and Midwifery, Paediatric and Anaesthetic staff to be informed.
• Use of G.I. prophylaxis both in the labour ward for high risk patients and prior to Caesarean Section
MEDIUM TERM RECOMMENDATIONS / PROPOSALS
• Trained Anaesthetists are able to visit Juba to provide training for the existing anaesthetic service (anaesthetic assistants).
• Request for voluntary help to all anaesthetists in the UK willing and able to offer their time and abilities via the Link (for a minimum period of two weeks).
• Those able to volunteer their services for longer periods ie six months may be considered for employment on local terms (the Government of Southern Sudan incentive scheme).
• Bring the Link’s charity aims and work to the attention of The Royal College of Anaesthetists.

LONG TERM STRATEGY / PROPOSALS
• Identify those Southern Sudanese doctors wishing to train in Anaesthesia and Critical Care Medicine, with the aim of contributing to their training.
• Visiting U.K. anaesthetists to Juba could offer training within a structured educational framework/programme.
• The development of exchange visits between Southern Sudan and the U.K for trainee anaesthetists from both countries.
• The Resource Centre – established in 2008 – could serve as a virtual link for training in Anaesthesia
• Critical care facilities can start to develop with the education, training and increasing numbers of staff (medical nursing and midwifery).
• Clinical Governance and Audit will compliment the above

i) There are two physicians, Dr Emmanuel Jermano Boyong assisted by Dr Magdy Ayad Hanna, who was employed by the Ministry of Health on the Incentive Scheme, to assist Dr Boyong with the management of the large number of extremely ill medical patients on the medical unit. Both physicians have undergone the three year Doctor of Medicine (in Medicine) Postgraduate Training in Khartoum and are competent clinicians. They supervise four Pre-registration House Officers, four Medical Officers (FY2 – ST1 grade) without the benefit of a Specialist Registrar. A Senior Medical Officer, Dr Thomas Akim Tako (ST2 equivalent) oversees work in the Emergency Medical Unit (EMU). Unfortunately from time to time he is also deployed to cover Medical Officers’ leave in other Units as well as covering the administrative duties of the Hospital Director in his absence.

ii) Inpatients
There are 93 inpatient beds, 34 in the emergency medical unit, 48 (male and female medical) and 11 isolation beds. Ward 5 is designated medical/paediatric with 52 additional beds which are used flexibly. Occasionally patients sleep on the floor if admissions are too many for the available beds.
iii) Investigations
The x-ray machine operates intermittently and during the visit was non-operational. Patients pay for x-rays (if they can afford them) at commercial facilities and bring their results to the requesting Clinician. There is no system in place for quality control and it is therefore difficult to assess some of the quality of the reports from these commercial imaging outlets. Basic laboratory tests such as HIV tests are available locally using kits. Urea & electrolytes, liver function tests, full blood count, erythrocyte sedimentation rate and various microbiological investigations are consistently unavailable. Computerised axial tomographic (CAT) scanning is not available, though the large number of people suffering head injuries, stroke, liver cancer, other cancers and hydatid disease dictate that such modality of imaging needs installing at Juba Teaching Hospital. CAT scanning would be useful in the differential diagnosis of subdural and extradural haemorrhage, ischaemic and haemorrhagic stroke. Ultrasonography is carried out by the two Physicians as part of their weekly duties or at a private clinic run by the only Radiologist in the Southern Sudan or an Egyptian Private clinic at a fee to the patients.

Almost all the patients on the medical wards were very ill with conditions ranging from malaria, meningitis, pulmonary tuberculosis, HIV/Aids, liver cirrhosis, hepatocellular carcinoma, unexplained ascites, the nephrotic syndrome, stroke, post traumatic brain injury, acute confusional states, bronchial asthma, heart failure, hypertensive crises, various parasitic infestations, Diabetic decompensation states, hydatid disease presenting as mass lesions to diarrhoeal diseases. On the whole these conditions are managed with minimum laboratory support but using clinical acumen mainly

iv) Trainees and Training
1. Eluzai gave talks to the Trainees on “Postgraduate Training in Juba, personal development and the role of Consultants as trainers”, “how to carry out clinical audit”, “the management of stroke in the acute stages” and “team work in clinical practice”.
2. Grand rounds were re-established and agreement reached with the Consultants to conduct them weekly on an ongoing basis.
3. Dr Louis Danga (SpR Paediatrics) volunteered to run a Trainee Journal Club once a month.
4. Trainees agreed to read the Southern Sudan Medical Bulletin online and use the Hospital Resource Room where there are six computers for self-directed learning.
5. As part of the exercise of learning how to develop an audit standard, both Consultants and Trainees came up with a dozen audit topics & standards which will be undertaken by various Trainees and Consultants to be presented in future Grand Rounds.
6. Preparation for higher examinations
• The Surgical Registrar (Michael Yatta) who is already proficient at carrying out laparotomies, appendicectomies and other aspects of abdominal and orthopaedic surgery, has passed the Parts 1 and 2 of the Membership of The Royal College of Surgeons (MRCS) examination through the overseas centre in Khartoum. He expressed the wish to gain United Kingdom experience through an attachment to a hospital in Britain before attempting the clinical part of the examination. This is a deserving candidate the Link could help achieve his ambition and turn him into a Trainer at JTH.
• The Paediatrics Registrar (Dr Louis Danga) has passed Parts 1 and 2 of the Membership of The Royal College of Paediatricians and Child Health (MRCPCH) and is preparing to sit the clinical part of the examination in the United Kingdom. He needs an attachment to a reasonable sized/busy paediatrics unit to gain experience and prepare to take the examination in the next twelve months.
• Three doctors at Medical Officer level are preparing to take Part 1 of the Membership of the Royal College of Physicians (MRCP) and MRCPCH, respectively. Eluzai and David Attwood are helping them practise with typical examination questions to guide their reading/revision. Questions will be e.mailed to them on a template and answers e.mailed a few days later. These candidates are self-selected and enthusiastic and their success will hopefully influence others to follow in their footsteps. The Link is strongly recommended to assist them in every way possible.

The Team saw the Minister of Health in the presence of the Director General for Curative Services (Hospital Services), Dr Yatta Lugor, and secured his endorsement for assistance with the construction of the Link House. The Team also saw the Undersecretary in the Ministry of Health on a separate occasion and obtained his support for building the Link House. Unfortunately Eluzai’s request for a written commitment from the Director General for Curative Services to provide top-up funding to the Link House Project was turned down by Dr Yatta on the grounds that the land on which the house will be constructed was sufficient contribution by the Ministry of Health. Further follow-up correspondence with Dr Yatta produced the same response.

The Juba Link Core Group both in the United Kingdom and Juba need to heighten their fundraising campaign to increase the available $50,000 US already in the kitty for erecting the Link House.

Eluzai discussed the Memorandum of Understanding between the Real Medicine Foundation (RMF), The St Mary’s Hospital – Juba Link and The Ministry of Health, Government of Southern Sudan with Mrs Janet K Michael, Director General for Nursing and Midwifery in The Ministry of Health (MOH). The proposal for the establishment of the School of Nursing was discussed in meetings with the Minister and Undersecretary at The Ministry of Health. The project was accepted in principle, but Mrs Janet Michael and her Directorate team wanted further clarifications of a number of points in the MOU in May 2009 when the RMF funders visit Juba prior to signing the MOU.

A further meeting with Miss Magda Armah, Deputy Head of the United Nations Family and Population Action (UNFPA) Juba Office and her team in Juba was very positive. Her team showed great interest and enthusiasm and offered to support the development of the school. Magda Armah pledged to support Janet Michael in the development and running of the school.

Eluzai met up with the Dean of the Faculty of Medicine at the University of Juba and the University Academic Secretary. Both were keen on the work of the Link at Juba Hospital. In 2010 the first batch of clinical students from the Faculty will undergo clinical tuition at JTH. The Dean pledged financial input into JTH to improve facilities in the Hospital in order to make the Hospital conducive to good quality clinical training. A meeting between the management of JTH, University of Juba and The St Mary’s Juba Link representatives was thought to be necessary in the near future to agree common ground on how high quality Undergraduate training would be delivered at JTH. In the meantime, the main concern of the Dean was lack of lecturers to teach physiology and biochemistry to the Second Year Medical Students. Until the previous year, physiology and biochemistry was offered by Khartoum based lecturers who, unfortunately, are too established in Khartoum to relocate to Juba. For the University of Juba to develop in Juba, it must employ or find preclinical and clinical lecturers to be based in Juba. The Link may be able to assist but is conscious of the risk of spreading itself out too thinly.

1. With 93 – 100 beds to look after without Specialist Registrar support the two Physicians are too stretched to deliver the expected high quality of care.

2. There is no dedicated secretarial support for the Consultants despite the high demand to refer patients abroad for treatment and tests. The delay in typing letters by the sole secretary in the entire hospital results in constant interruptions of clinics and ward rounds by people following up progress on their letters of referral.
3. Lack of diagnostic services – poor laboratory, lack of simple x-ray, ultrasound and CT scanning, making clinical decisions difficult.
4. Bedside teaching of Pre-registration House Officers, Medical Officers is compromised by the busy Consultant schedule.
5. Lack of diagnostic endoscopy service for this tertiary referral hospital (serving a country the size of France) means patients are referred to neighbouring African countries, India, South Africa, Jordon or the United Kingdom at costs of between $15,000 – $24,000 US per patient.
6. Patient records are often not available when re-admitted because the filing system has not been fully developed. This is bound to compromise the continuity of care.
7. Despite rigorous training of nurses by Drs Attwood and Ayrton on the value of recording vital signs, Eluzai observed that several patients did not have a record of their signs on his first ward round on the 20 March 2009. This had improved to some extent by the 3 April 2009.
8. Regularity of Ground Rounds had waned prior to the Trainers visit in March but it is hoped that this will be rectified and continuity re-established.
9. No organised provision of food for patients. Those without relatives to cook for them or bring in food literally starve

1. Volunteer Physicians who are able to spend a month to three months to JTH to relieve Dr Emmanuel, who has not taken leave in twelve months, would be a welcome solution.

2. The establishment of a Diagnostic Centre needs urgent consideration. The large sum of money currently used for investigation and treatments abroad could easily be invested in the development and management of a local diagnostic centre.
3. A secretary for the Medical and Surgical units and another for the Obstetrics & Gynaecology and the Paediatrics Units would be a good start.
4. Specialist nurses in Diabetes, Paediatrics, Orthopaedics, Emergency Medicine and Senior Midwives would greatly improve the quality of healthcare delivery at JTH.
5. Provision of food for patients at the Hospital must be organised as soon as possible. The Hospital needs a dedicated budget to cater for feeding patients. The Juba Link and other organisations with interest in developing training at JTH need to work together to find a sustainable solution to feeding patients
Nursing Report by Noreen Collins and Sharon Evemy

(i) Staffing Levels
There is a total of 141 nurses in JTH made up of The Matron, 14 registered nursing sisters (trained in Khartoum) and 126 certificated nurses trained locally in Juba and working on 22 wards. The registered nurses are all recently qualified and relatively inexperienced. The certificated nurses have attended courses ranging from two weeks to two years. A very small number of nurses speak or write in English. In general the Sisters give very little guidance to their staff and perceive that they are shown no respect by the certificated Nurses.
There are problems with absenteeism on a regular basis as nurses sometimes take up other jobs which pay better. A number are willing to forego their pay at JTH for a day or two on a regular basis to work elsewhere for better remuneration. Due to the fact that such duties are unanticipated they inevitably have adverse effect on the nurses’ rota and cause disruption to the ward staffing levels and ward dynamics. Transport provided for senior nurses is frequently late and results in the English speaking nurses missing the early morning doctors’ round on the ward thereby compromising vital exchange of information about the patients on the wards. Some nurses who possess specialist skills are not placed in the appropriate clinical setting but are rotated through various departments resulting in loss of valuable skills for the appropriate patient groups. Patient care is affected and valuable teaching and dissemination of information is, therefore, lost in the process.
There are no basic observations of vital signs taking place on any ward except the emergency medical ward, where Drs Attwood and Ayrton, the two foundation year Doctors from the UK who worked and taught there for four months in 2008..

(ii) Reasons for lack of carrying out Observations on the Wards:
• Lack of equipment such as thermometers and sphygmomanometers
• Lack of charts to record such observations (due to lack of paper in the hospital) and difficulty to photocopy the charts because of irregular access to the photocopier due to intermittent electricity supply. The copying of charts generally involves a member of staff spending a significant part of the day trying to complete this task when they would be better employed caring for patients.
• Nurses do not feel empowered to carry out procedures unless specifically requested by a doctor.
• Lack of appropriate skills and practice. Out of 27 third year nursing students only 5 could take a blood pressure measurement correctly. There is no practice or mentoring arrangements on the wards.
• Students who were in their fourth year had not yet taken their final exams as the exam papers had no been sent over from Khartoum. There was an additional issue of a budget to pay lecturers and support the functioning of the school. Students who were due to take their finals in May 2009 were not optimistic of doing so. Some were abandoning their Nurse training and seeking job opportunities in other fields.

We met with the senior nurses from each ward and identified the following key issues that needed to be addressed:
• Poor communication between doctors and nurses, between the nursing staff on the wards as well as interdepartmental communication. Many of the sisters cited examples of un-cooperative nursing staff who declined to carry out what was asked of them regarding patient care. This led to the nurses in charge feeling disempowered and patient care being compromised.
• Lack of supervision for junior/less qualified nurses
Most of the sisters were very motivated and wanted to improve their skills. They would all like further training and/or regular workshops for all nurses.
They all asked for more guidelines to inform their daily practice.
• A general frustration with the lack of vital supplies to the departments…running water, gauze, lotions, catheters (not one urinary catheter could be found in the stores during our stay)Nasogastric ( NG) tubes, mattresses and bed. A shortage of mosquito nets in most wards though some were available on the eye unit only.
• There is no system for provision of food for patients. Patients without family to cook for them do not have anything to eat. Two nurses who form the Social Services Team are able to provide some food on an irregular basis to a few patients using an intermittent and unpredictable supply of petty cash.
• Disposal of placentas in the Labour ward remains a problem as the incinerator has not been repaired. Some women who do not wish to take their placentas home will try and dispose of them in the general rubbish bin or attempt to flush them down the toilet. This has resulted in toilet blockages.

Following this meeting and our own nursing needs assessment, and aware of the limitations of our short visit, we decided to concentrate on:
• Training Nurses on basic observations and recording of vital signs throughout the hospital
• Implementation of a very basic care plan which both nurses and doctors welcomed
• Simple ways of improving nursing team dynamics through some multi disciplinary team working examples and role play.

Afternoon Workshops were held with a daily attendance of between 18 – 26 nurses who all received a certificate for attendance. Each workshop received favourable comments from those who attended. Topics covered included:
• Admission of the very ill patient
• Nursing Assessment
• Monitoring a patient receiving Blood Transfusion
• Shock and haemorrhage
• Multi disciplinary team working
• Principles of good communication and team leadership
• The importance of patient care planning
A session was spent in the Hospital Resource room to illustrate how nurses could access information online for research, reading nursing journals and accessing websites for information relevant to their practice and personal development.
It was unfortunate to note that planned sessions on Aseptic technique/Dressings were cancelled due to lack of water and equipment.
(iii) A critical incident meeting attended by Noreen Collins, and Sharon Evemy, Fiona Dr Henderson, Dr Mirghani Abdalla (Obstetrician and Gynaecologist) and Sr.Jamelia Sake(Maternity Sister) was held to discuss the events leading up to the death of a baby in the maternity unit and how such an incident might be avoided in the future. It was agreed to adopt a policy whereby any high risk obstetric patient admitted to the hospital will trigger a chain of actions. The admitting Medical officer will have the responsibility of informing all relevant clinicians, such as the duty Consultant Obstetrician, Senior Midwife, Consultant Paediatrician and Theatre personnel of the presence of the high risk patient in the delivery suite or on the antenatal ward. This will alert personnel to be available to be called in the event of an emergency occurring during labour or at delivery to avoid unnecessary delay in intervention by a senior Clinician or midwife. The meeting thought this would have a positive effect on maternal and perinatal mortality. It was estimated that were y between two and four complicated deliveries at Juba Teaching Hospital daily.

Another meeting was held with the link nurses and the senior nurses from the Directorate of Nursing and Midwifery. The issues of training and clinical mentorship were discussed. There was a specific request from the Directorate of Nursing and Midwifery for help from the Juba Link with the supply of clinical guidelines and a code of ethics for the proposed new nursing council.

(iii) Recommendations for the Future
The proposed School of Nursing and Midwifery in Juba is unquestionably the way forward. There is an urgent need, however, to support the nurses currently working on the wards at JTH with ongoing education in order to raise basic standards. A small number of motivated sisters have been identified as suitable clinical trainers if given the appropriate support. This needs to be implemented long before the first diploma nurses start training. This will result in improved patient care and a reduction in mortality rates. In the interim the Sisters could have help from the Link with Training material in the form of structured packages or modules of training material supported by further nurses’ visits from the United Kingdom through the Link.

Having raised the basic standard on the wards, the hospital environment will hopefully be suitable for hands-on training of student Nurses. This can be monitored and provided on an ongoing basis by Senior Nurse volunteers from the UK through the Link.
• Appropriately skilled nurses at JTH should be deployed in the appropriate ward setting and encouraged to train others through sharing of information and mentoring.
Four senior members of the nursing directorate, Anita Petero Modi, Petronella Wawa, Vicky Akoowa and Mary Rose Joah, have agreed, if this can be arranged, to take turns in supplying senior nurse skills on the wards as visiting clinical nurse tutors. This would be invaluable in improving standards before the start of the nursing and midwifery school.
• The link nurses have agreed to obtain information on nursing ethics and guidelines for use as Guidance in the new Juba School of Nursing and Midwifery to develop local policies on Nursing and Midwifery ethics and regulation.
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• Frances Tombe, The Head of the Hospital Health Resource Centre, has agreed to teach computer skills to small groups of nurses on a weekly basis to foster computer literacy and enable nurses to access nursing research and information online. This is encouraged and needs immediate implementation.
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• Problems such as procurement of stores, pharmacy supplies, nurses’ transport, access to photocopying and printing charts are organisational and administrative issues that should be addressed through the newly formed multi professional hospital management committee which was recommended by Dr Hakim at a Hospital staff meeting..
Our thanks are due to the Ministry of Health for paying for our accommodation during the visit and to The Juba Link Committee for making us welcome in the Hospital and facilitating transport between the Hotel and the Hospital. In particular we would like to thank the following :
1. His Excellency Dr Joseph Manytuil Wejang -Minister of Health.

2. Dr Majok Yak Majok -Undersecretary Ministry of Health.

3. Dr Yatta Lugor Lori -Director General Curative Services MOH.

4. Dr Gabriel Thuou Apac Loi -Director, Directorate of Curative Services.

5. Dr Dario Kuron Lado- Director General JTH & Surgeon

6. Dr Hassen Chollong- Chairman Link Committee & Paediatrician

7. Dr Louis Danga-Member Link Committee Juba.

8. Dr Betty Ayub. Consultant Dentist and Treasurer Link
Committee Juba.-

9. Dr Emmanuel Jermano Boyong-Consultant Physician and Host to Eluzai Hakim.

10. Dr Magdy Ayad Hanna -Consultant Physician and co-host to Eluzai Hakim.

11. Dr Merghani Abdallah -Consultant Obstetrician and Gynaecologist.

12. All the Consultants and Medical Officers JTH

13. Janet Michael -The Director of Nursing and Midwifery Services

14. Susan Poni Dila -Matron

15. Sr. Lucia Thomas -Ass. Matron/Senior Paediatric nurse

16. Sr. Lorna Jackson Ass. Matron/Senior Nurse-

17. Sr. Sake Jamelia -Senior Midwife

18. Sr. Anna Martin -Emergency Medical Ward

19. Mr. Frances Tombe -Manager Resource Room

20. Charity Ja’be -Medical Secretary

21. William Lual Gang- Senior Hospital Administrator

22. Ewinio Rumudu Alakai – Senior Hospital Manager

 

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