Child illness and deaths remain high in the Solomon Islands, as in many Pacific countries, and the number of health workers is inadequate to provide the services required. A comprehensive child health programme that can further reduce child mortality and address significant morbidity issues has many components; acute clinical care, immunisation, nutrition, public health, coordination of care for chronically unwell children. Each of these components is increasingly complex, with the introduction of new treatments, increasing antimicrobial resistance, emerging disease threats, and the recognition of previously neglected areas (such as neonatal care, adolescent health, child protection and disability). With these demands, and the reality that there will not be sufficient doctors to address these needs in remote areas in the Pacific, there is a need to equip nurses with the skills required in these areas.
The issue of child health nurses worldwide has received almost no attention, despite the global push to improve child survival. There have been few previous studies examining the roles of child health nurses in developing countries, and we could find only one from Lesotho . A few studies have focused on training nurses in narrower speciality roles, such as paediatric oncology , neonatal resuscitation , or the advanced paediatric life support programme . Invariably these studies have focused on the contribution of nurses or doctors from Western countries to the training of nurses in developing countries . There is no previous study to have evaluated the long-term output and outcomes of local child health nursing education in a developing region.
This study provides evidence that nurses can fulfil the roles required by a provincial health service in a developing country in the 21st century, long after they have completed training. In the Solomon Islands, child health and paediatric nurses were employed in vital clinical, public health, management and teaching roles. Many worked as sole practitioners in remote provincial settings where there were no doctors. Most were called upon to advise and assist junior doctors as they were the clinicians with the most experience in child health at their hospital or health centre. This has implications for paediatric care across the country, and creates opportunities for an appropriate approach to the human resource of countries such as the Solomon Islands in this time, towards and beyond the MDGs.
Overall, the nurses gave positive feedback about the quality of training in the 12-month residential diploma in paediatrics, or paediatrics and midwifery through UPNG. A recurrent theme was relevance; that such courses, with their emphasis on clinical competency, mentorship and supervision, equipped nurses to function independently, particularly in remote, isolated settings. However, the PNG paediatrics post-graduate course, and support required to undertake it, is expensive at approximately (SI $180,000 per nurse per year). There is also a drain of skilled staff, albeit temporarily, and overseas training results in the removal of the nurse from the local workforce for 12 months. Most concerning for nurses involved in overseas training, was the separation from their families and communities. No Solomon Island nurses have been trained at the University of PNG since 2006 for reasons of cost, social dislocation and concern about the combined midwifery and child health course not providing a sufficient level of competency. UPNG has now reverted to single midwifery and child health programmes because of concerns that the combined course did not allow the students to obtain the required competency level in the time provided, and these reforms have been positively received. However there is now only one post-basic child health nursing course in PNG, where formerly there were four. The advocacy for midwifery training, appropriate given the high maternal mortality in the Pacific, has overshadowed the need for training more child health nurses and the need for re-establishing colleges who can train such staff. Redressing of this imbalance is urgently needed.
The nurses in this study who had had undertaken a distance education certificate identified as challenges, the lack of supervised clinical training, difficulties in accessing the technology, and the inappropriateness of the content and delivery method to the local setting.
Other local initiatives have attempted to address the lack of training opportunities for nurses, including a programme for training provincial nurses on the management of seriously ill children using the WHO Pocketbook of Hospital Care for Children. Two hundred nurses in all provinces have been trained in the use of these guidelines . The Integrated management of Childhood Illness (IMCI) training was also conducted in selected provinces, but has not been scaled up nationally . Interviewed nurses concluded that there was a need for in-country post-graduate training for nurses in child health. The current numbers of post-graduate child health nurses provide inadequate and fragmented cover.
This study has demonstrated the need for advanced paediatric trained nurses in the Solomon Islands, and its value in equipping nurses who work in remote areas with capacity to fulfil the roles required of them. Current modes of delivery have not been able to fulfil this need according to the nurses interviewed. More than 120 graduates from the Solomon Islands post-graduate midwifery course, facilitated jointly by the Ministry of Health and Solomon Islands College of Higher Education for over 15 years, are now widely distributed throughout the Solomon Islands. This has been a substantial success. This success could be replicated with a locally delivered, content-appropriate nursing course in paediatrics and child health. The content of such a course would be based on the child health needs of the Solomon Islands, and draw upon the many training resources and standards from WHO, United Nations Children’s (Emergency) Fund (UNICEF) and other agencies in recent years [15–18], and would also draw upon the UPNG course.
There are resource implications. However many of the ingredients are in place and this type of course can be relatively low budget yet still of high quality. Such a course is ideally practically based, therefore, much of the training would be conducted in the paediatric ward at the NRH. This requires input from clinical teachers and paediatricians; however, there is a benefit to quality of care even while the students are training. This is because of the increased focus on clinical teaching, and the level of critical enquiry that ensues from becoming a teaching institution. There are classrooms at most major hospitals for theoretical teaching, so infrastructure requirements are minimal. The public health teaching required for such a course is largely practical, and requires involvement of public health branches of the health department, both national and provincial, plus travel to rural areas for practical experience of public child health programs. Clinical nurse teachers need higher training, and most nursing colleges in the Pacific require teachers and lecturers to be trained to Master’s level in nursing or education. This could be facilitated in collaboration with universities in Australia. However even if provided for only two or three nurse teachers (the number required to establish a course training 15 to 20 paediatric nurses per year), this would require substantial funding. Higher degree education in Australia is expensive at approximately AU$25,000 for a Master’s degree, plus travel and living expenses, which can cost an additional $40,000 a year. The graduates of a paediatric nursing course would require professional and legal recognition and accreditation for a wider scope of practice. There are precedents in midwifery, but changing accreditation and legal recognition requires political will and action, as well as modest but ongoing funding for higher wages for specialist nurses.