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R e s e a r c h A r ti c l e

Training nurses to save lives ofmalnourished children

T Puoane, Dr PHSchool of Public Health, Uii iversity of the Western CapeD Sande rs, M.B. Ch BSchool of Public Health, University of the Western CapeA Ashworth , PhDNutrition and Public Health Intervention Research Unit, London School of Hygiene & Tropical Medicine, UKM Ngumbela, B (Cur)Eastern Cape Department of Health

K e y w o r d s :Malnourishment, attitudes,WH O treatment guidelines

vate Ba g.X n,

A b s t r a c t : C u r a t i o n i s 2 9 ( 1 ) : 7 3 - 7 8A qualitative study with a pre- and post-intervention component was undertakenamong 66 professional nurses at 11 hospitals in the Eastern Cape to assess theirperceptions and attitudes tow ards severely malnourished children and their mothers/caregivers . Nu rses' attitudes were compared b efore and after attending a 5-day trainingcourse to improve the management of malnutrition along with implementing WorldHealth Organization (W HO) guidelines.Severe malnutrition is a major cause of death among paediatric patients in manyhospitals in South Africa. A qualitative study with a pre- and post-interventioncomponent w as undertaken am ong 66 professional nurses at 11 hospitals in the EasternCape to assess their perceptions and attitudes towards severely malnourished childrenand their mothers/caregivers. Nurses' attitudes were compared before and afterattending a 5-day training cou rse to improve the management of severe malnutritionthrough imp lementing the World Health Organisation (WHO ) guidelines.Focus group discussions were conducted in isiXhosa following a semi-structureddiscussion guide. Three themes emerged from these discussions, i.e. nurses placedblame on the mothers for not giving adequate care at hom e; nurses valued malnou rishedchildren less than those with other conditions; and nurses felt resentment towardscaregivers. Underlying reasons for the negative at t i tudes towards severelymalnourished children and their caregivers were misunderstandings of the causes ofmalnutrition, misinterpretation of clinical signs, especially poor appetite, and highmortality d uring treatment.How ever, the training course and successful application of the treatment g uidelinesaltered these perceptions and helped nurses to have a better understanding of thecauses of the presenting clinical signs. These nurses have begun advocating forraised awareness of the phy siological differences that occur in malnutrition and theneed to include the WHO Ten Steps of treatment in the nursing curricula and in-service training. A cadre of volunteer nurse-trainers has been formed in Eastern C ape.Experience in this province has shown that in-service training changes attitudes tomalnutrition and treatment practices, as well as saving lives.

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die Oos-Kaap onderneem om hul lepe rseps i e s en houdi ngs j e ens e rgeondervoede kinders asook teenoor hullemoede rs / ve rsorge rs va s t e s t e l .Ve rp l eegkundi ges se houdi ng s i sverge lyk voor en na 'n 5-dagopleidingskursus om die beheer vanwanvoed ing te verbeter deur middel vandie implementer ing van dieWereldgesondheidsorganisasie (WGO)se riglyne.Inges t e l de g roepbesprek i ngs i s i nisiXhosa gevoer met behulp van 'nsemigestruktureerde besprekingsgids.Drie temas het uit hierdie besbrekings navore gekom, i.e. verpleegkundiges hetskuld o p moeders geplaas w eens nalatigeversorging, verpleegkundiges het minderwaarde aan ondervoede kinders gehegas aan diegene met ander toestande, enverpleegkundiges het gegriefd teenoorversorgers gevoel. Onderliggende redesvir die negatiewe ho udings teenoor ergewangevoede kinders en hulle versorgerswas wanopvattings ten opsigte van dieoorsake van wanvoeding, mis inte r-pretasie van die kliniese tekens, veral 'nswak aptyt en die hoe morta l i t e i tgedurende behandeling.Nogtans het die opleidingskursus ensuksesvol le toepass ing van diebehandelingsriglyne hierdie persepsiesgewysig en verpleegkundiges gehelp om'n beter begrip te he van die oorsake vandie kliniese tekens wat teenwoordig is.Hierdie verpleegkundiges het beginbepleit vir 'n groter bewustheid, van diefisiologiese verskille wat gepaardgaanmet wanvoeding en d ie behoefte aan dieinsluiting van die WGO se Tien Stappevan behandeling by die verplegings-kurdkula en indiensopleiding. 'n Kadervry williger verpleeg instrukteurs is in dieOos-Kaap gevorm. Ondervinding inhierdie provins ie he t ge toon da ti nd i ensopl e i d i ng houdi ngs j e enswanvoeding en behandelingspraktykeverander, asook lewens red.Oh no! It 's a Kwashy again. Look at you(the mother); you are well-dressed whilethe child is malnourished. What iswrong with these mothers?They (the children) are supposed to dieanyway. They are not important.Listening to these comments by twosenior nurses makes one wonder why

I n t r o d u c t i o nMalnutrition in children remains a leadingcause of morbidity and mortality in SouthAfrica, and severe malnutrition is a majorcause of death among paediatric p atientsin many hospitals. The reason for thelatter is not that there are more admissionsfor severe malnutrition than for otherconditions but rather because a greaterproportion of them die during treatment.For exam ple, in 11 rural hospitals in theEastern Cape Province, on average 22%of paediatric admissions with severemalnutrition died during the first half of2004 compared to 9% of children withother conditions. Many malnourishedchildren die unnecessarily because ofoutdated practices and staff memberswho are unaware of their special needs(Ashworth, Chopra, McCoy, Sanders,Jackson, K araolis, Sogaula & Schofield,2004:1110).Severely malnourished children are oftenknown to be miserable, irritable, andanorexic. If basic principles of treatmentare not followed, recovery is slow andtypically, 20-30% of these children die(Schofield & Ashworth, 1996:223). Insome S outh African hospitals, mortalityamong severely malnourished childrenapproaches 50% (Puoane , Sanders ,Chopra, Ashworth, Strasser, McCoy,Zulu, Matinise & Mdingazwe, 2001:138).In such circumstances, it is perhaps notsurprising that their arrival at the wardoften leads to frustration and irritationamong nurses.In an effort to reduce deaths frommalnutrition and improve recovery, theWorld Health Organization ( W H O , 2000:80-91) guidelines for managing severemalnutrition (WHO, 2000:1-162) werepiloted in two rural hospitals of theEastern Cape, in 1998. Key messagesbased on the WHO's Ten Steps wereformulated, and a training course andguide (Ashworth, Puoane, Sanders &Schofield, 2003:1-206) w ere developed tofac i l i t a te implementa t ion in otherhospitals in southern Africa. Until now,health professionals from 27 SouthAfrican hospitals have been trained.This article reports on the attitudes ofnurses towards severely malnourishedchildren and their mothers/caregivers,and how these attitudes changed afterhaving attended a training course along

wasting and/or oedema ( W H O , 2000:8and i nc l udes t he syndromes kwashiorkor (oedematous malnutritionmara smus ( seve re was t i ng) , anmarasmic kwashiorkor (severe wastinwith oedema).

S e t t i n gThe project is based in the formTranskei, an apartheid-era homelansi tuated in one of the most underesourced regions in South Africa. Tharea includes three districts and 1hospitals, i.e. Alfred Ndzo district (MaTheresa, Mt Ayliff, Sipetu, Rietvlei, anSt Margaret 's Hospitals), O.R. Tamdistrict (St Patrick's, Greenville, HoCross , St El izabe th and BambisaHosp itals), and part of Ukahlamba distr(Taylor Bequest H ospital).T r a i n in g c o u r s e a n dm a t e r i a l sThe Eastern Cape Departm ent of Healhas supported the training of hospitstaff since 1999 to improve tmanagem ent of severe malnutrition wia 5-day course deve l oped by tUniversity of the Western Cape and tLondon School of Hygiene and TropicMedicine. The course is interactive aparticipatory, and invo lves: group work, to provide an

opportunity for self-learningthrough logical reasoning anresolving problems, andpromote deep learning thatwill not be forgotten;

role-plays, to facilitatediscussions and raise sensitiissues, and to illustratephysiological mechanisms adifficult concepts in amem orable and light-heartedway;

practical exercises to testknowledge and practise newskills;

questions and answers, to draforth kn owledge and apply thto managing malnourishedchildren;

key messages, as a summarythe principles for m anagingseverely m alnourished childr

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The course and materials follow theprinciples of care set out by the WHOfor managing severe malnutrition (WH O,2000:80-91). In 2000, the development o fa Training Guide was undertaken to helpothers organise and teach this course,and thus accelerate repl icat ion andimplementation (Ashw orth, et a l . , 2003:1 -2 0 6 ) . The Guide contains all the coursematerials that trainers and the trainingDirector wil l require. Handouts andtransparencies used during the coursecould be used by participants to traintheir own staff when they return to theirrespective hospitals. The course contenthas also been summarised in a book,'Caring for severe ly malnouri shedhildren' (Ashworth & Burgess, 2003:1-7 9 ) .

M e t h o d sthers/caregivers, with a pre-

p o p u l a t i o no were directly involved in the

1 1 first-itals in th e Eastern Cape

a t a c o l le c t io n

ng w orkshops, and iii) 6-12 m onthser the training wo rkshops.( i ) . Before each of th e six training

2000/01, focus group

a n d attitudes towardsi-structured discussion

children was assessed (Puo ane, Sanders,Ashworth, Chopra, Strasser & McCoy2004:35-39). Case-fatality rates werecalculated by dividing the number ofdeaths of severely malnourished childrenby the number of severely malnourishedadmissions times 100.Phase ii). During the s ix t ra iningworksh ops, nurses were given a scenarioand requested to di splay a t t i tudestowards malnourished children throughrole-play:" Y o u a r e a nurse woricing in a paediatricward. During tite past two weeics, tiierehave been admissions of malnourishedchildren on a daily basis. Y o u have beenbusy giving out medicines when yousuddenly see a m other sitting in a chairwith a malnourished child. Pleasedisplay your attitude towards thismother".

Phase (iii). After 6-12 mo nths, evaluationvisits to the 11 hospitals were made togather data about case-fatality rates andthe extent to which the guidelines werebeing followed w ith the use of a checklist.Previously trained nurses who had beenimplementing the guidelines for about 6-12 months were also invited to theworkshops to share their pre- and post-t ra ining experiences of case-managem ent. Two nurses were invited toeach training workshop with 12 nursessharing their experiences.D a t a q u a l i t yTriang ula t ion ( i . e . com paring da taobtained by one m ethod with similar dataobtained by another method) was usedto demo nstrate validity of the qualitativefindings. For examp le, attitudes tow ardsthe arrival of a malnourished child on theward obta ined through focus-groupdiscussions were compared with thosedisplayed in role-plays. Information w asalso referred back to participants toensure trustworthiness of data.D a t a a n a l y s i sDiscussions were transcribed, translatedinto English, and analysed for content toidentify the main themes. D irect quotesfrom the focus groups, role-plays, andtes t imonies were used to i l lus t ra teperceptions and attitudes.

Western Cape. All part icipants whoconsented to the study were informed oftheir right to refuse participation orwithdraw from the study without havingto give reasons . Par t ic ipants wereguaranteed confidentiality.F i n d i n g sI n - p a t ie n t c a r e p r a c t i c e sThe findings on the "In-patients carepractices" and "Attitudes towards thechildren and carers" are findings atbaseline ( i . e . before the intervention).The"Testimonies of nurses who had beent ra ined previously" i s a f te r theintervention. At baseline, quality of carewas reasonably satisfactory at RietvleiHos pital, with a case-fatality rate of 1 0 % ,but e l sewhere t rea tment of severemalnutrition w as inappropriate and noneof the Ten Steps was adequate lypractised. Triage was absent and therewere long delays in adm itting children tothe ward. Diuretics were incorrectlyprescribed to t reat oedema therebygreatly increasing their risk of heartfailure. Children with diarrhoea oftenrece ived int ravenous (IV) f luidsindiscr imina te ly, thereby grea t lyincreasing their risk for heart failure,antibiotics were not routinely prescribed,and e lec t rolyte and micronut r ientdeficiencies w ere not corrected. Specialfeeds were not prepared andmalnourished children simply receivedsmaller portions of the general adult warddiet. They w ent without food for up to 11hours at night, thus risking death fromhypoglycaemia. Play and stimulationwere not provided and there was nocontinuity of care after discharge. Thehospitals lacked many basic resourcesincluding naso-gastric tubes, vitamin Acapsu l e s , mul t i v i t ami ns , and bo t hpaediatric and dietary scales. Wards wereoften cold and overcrowded. Somemalnourished ch ildren were nursed in thesame bed a s children with other infectiouscondit ions, including meningit is andgastroenteritis. There was no provisionfor mothers or carers to stay over a t night,children were w eighed infrequently, andhygiene was genera l ly poor . Sta ffconsidered car ing for the severe lymalnourished children t o b e unrewarding.Case-fatality rates in 1999 ranged from1 0 % (Rietvlei) t o 4 5 % (Holy Cross) w itha median of 2 8 % .

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malnu trition, which created awareness ofthe need to treat the children differently,including feeding, rehydration, use ofantibiotics, and the importance of play.Included were the following qu otes:We thought these children have beenneglected by mothers. We did not knowwhat was going on physiologically.When I w as sitting in the lecture room, Iwas thinking of the child that wasadmitted ust before I left or the training(and put o n a drip) and praying veryhard that I must find him alive. But onarrival back to the hospital at the endof the training I found that he had died12 hours before my arrival. I could not

myself.When I was told that I was going toattend a training workshop about themanagement of malnourished childrenI asked my matron "what is new aboutthis Kwashy " ? We have been managingthese children for years! But at the endof the session on physiological changesthat occur in malnourished children, Ictually told the facilitators that we haveilled many children thinking we wereoing the correct thing by giving high

Understanding the physiologicalhanges that occur in malnourishedo be treated differently from otherhem. We thought that these childrenacked proteins and we therefore gave

igh protein diet.

feeding 3-hourly to preventWe thought sister-in-charge was just

we sometimes recorded the feedschild. After

the programm e and(starter formula), we saw a

in statistics (fewer deaths) and

never used to give antibiotics even ifwe thought that these

be fed.

without playing with them. Instead, wegive them names to suit theirappearance or just call them Kwashy-Kwashy.When we touch them, they start crying,we therefore prefer to leave them a lone.Smiling is a sign of recovery. Everyoneshould be trained about themanagement of severe malnutrition. Itshould be included in the basic nursingcurriculum.The training also changed their attitudetowards caregivers and they spokeabout , needing to be sympathetic tomothers. When the mother arrives w itha malnourished child, we now explainwhy the child is sick. We also explainthe type of eeds that will be given.Cas e- fata li ty ratesOverall, median case-fatality rates fellfrom 28% to 22 % after training . A strikingexample w as Holy Cross Hospital wherethe morta l i ty among severe lymalnourished patients was 4 5 % in 1999,and fell to 8% within twelve months ofthe staff being trained. Not all hospitalshave experienced such dramatic changes:the reasons a re var ied but inc ludefrequent staff turnover, emigration, staffi l lness, poor leadership, and lack ofsupe rv i s i on and account ab i l i t y(Ashworth, et al., 2004:1110-1115).D i s c u s s i o nSeverely malnourished children arecomm onplace in rural hospitals in SouthAfrica . The care of severe lymalnourished children is primarily nurse-led. Nurses are their hfehn e; therefore, itis essential that they have the know ledgeand skills to make the correct decisionson the management of these children.However, this is not happening. Theirknowledge is inadequate, and treatmentpractices are poor and do not followintemational guidelines. In the study itwas found that the prevaihng view wasthat severely m alnourished children justneeded feeding. The test imony thatantibiotics were never given, even ifprescribed, because, we thought thatthese children only needed to be fed,iUustrates the gravity of this erroneousview. The consequence is that childrenare dying unnecessarily, and in large

which in turn adversely affected thequality of care.There w as also lack of awareness of theprofound physiological changes that takeplace in severe malnutrition and the needt o cons i de r t he se when prov i d i ngtreatment. Poor appetite, which is socommon in malnutrition, was perceived

as an idiosyncratic trait rather than afeature of infection. Consequently, littleeffort was made to overcome anorexia,apartfromgiving IV fluid and thus riskingheart failure and death.Training, on the other hand, altered theseperceptions and helped nurses to have abetter understanding of the causes of thepresenting clinical signs, the impo rtanceof coaxing children to eat, feeding bynaso-gas t r ic tube , and correc t ingelectrolyte imbalances and micronutrientdeficiencies. This also provided a betterinsight into the need for antibiotics, thedangers of f luid overload and theimportance of keeping children w arm.As far as the quahty of care is concem ed,the study revealed negative attitudestowards malnourished children and theirmothers, with adverse effects. Lack ofproper matem al care was seen as a majorcausal factor in the development ofmalnut r i t ion, and thi s engenderedreproachful attitudes to caregivers andresentment that was not seen with otherillnesses. Malnourished children wereseen as a burden that could have beenavoided with proper care at home. G iventhis attitude, and considering the pro blemof understaffing, it is understandablewhy nurses may have felt demotivatedand lowered their own standards of careas the following testimony indicates: Wesometimes recorded the feeds withoutgiving them to the child. Negativity wasoften s t rong, as exempl i f ied bystatements about the inevitability ofdeath in malnourished children and theneed to die.

In contrast, after training and seeing areduction in mortaUty that is associatedwith implementing the W HO guideUnes,motivation and quality of care improved.The nurses were also more likely toexpress sympathy rather than blamingcaregivers.

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are thus not adequately equipped tomanage such children, a situation thatneeds to be rectified. Man agem ent of thiscondition is also not adequately dealtwith in the curriculum for paediatricnursing.Updat ing and upgrading the bas icnursing curriculum should be a priority.This should include the physiologicalchanges that occur in severe malnutritiona l ong wi t h t he WHO t rea t mentguidelines. In-service training is alsoneeded. Materials already exist, such asthe trainers ' guide (Ashworth, et al.,2003:1-206) which includes overheads,role-plays etc. that can be utilised fortraining n urses, as well as the book thathas been specially written with nurses inmind (Ashworth & Burgess 2003:1-79).All the information needed to managesevere ly malnouri shed chi ldren i sprovided, and both the guide and bookare available on CD ROM .Case studies to practise different asp ectsof care are available from the first autho r(TP). Experience in the Eastern Cape, asillustrated in this article, has shown thatin-service training changes both attitudesto malnutrition and treatment practices,as well as saving lives. Building on thisexperience, the Eastern Cape Departmentof Health has formed a cadre of volunteernurse-trainers w ho can be called upon tosupport training in the province. Sim ilarwork has comm enced in the provinces ofLimpopo, Kwa-Zulu Natal, and NorthWest where comparable situations havebeen found to exist.

R e f e r e n c e sASHWORTH, A & BURGESS, A 2003:Caring for severe ly malnouri shedchildren. London: Macmillan. Also,Teaching-aids At Low Cost (TALC) [OnLine]. Available: http://www.talcuk.org[2005, October 31].A S H W O R T H , A ; C H O P R A , M ;MCCOY, D; SANDERS, D; JACKSON,D,- KARAOLIS, N; SOGAULA, N &SCHOFffiLD, C 2004: WH O guidelinesfor management of severe malnutritionin rural South African hospitals: effecton case fatality and the influences ofoperational factors. Lancet. 363: 1 1 1 0 -1115.

Teaching-aids At Low Cost (TALC) [OnLine]. Available: http://www .talcuk.org[2005, October 31].PUOANE, T; SANDERS, D; CHOPRA,M; ASHWORTH , A; STRASSER, S;MCCOY, D; ZULU, B; MATINISE, N &MDINGAZWE N 2001: Evaluating thec l inica l management of severe lymalnourished children - a study of tworural district hospitals. South AfricanMedical Journal. 91 :1 3 7- 4 1.P U O A N E , T ; S A N D E R S , D ;A S H W O R T H , A ; C H O P R A , M ;STRASSER, S & MCCOY, D 2004:Improving the hospital management ofmalnourished children by participatoryresearch. International Journal for Oualityi nHea l t hC a re . l 6 : 31-40 .SCHOFIELD, C & ASHWORTH, A1996: Why have mortal i ty rates forsevere malnutrition remained so high?Bul le t in of the World Heal thOrganization. 74:2 23 - 229.WORLD HEALTH ORGANIZATION2000: Management of the child with aserious infection or severe malnutrition:Guidelines for care at thefirst-referral evelin developing countries. World HealthOrganization: Geneva. Also, [On Line].Available:ht tp: / /www.who.int /chi ld-adolescent-hea l t h / pub l i c a t i ons / re fe r ra l _ca re /homepage.html [2005, July 14].

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