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Auxiliary nursing: Danger waiting to happen?

FUNMILAYO AREMU-OLAYEMI examines the concept of auxiliary nursing, its functions in a healthcare system, the difficulties other medical professionals encounter while working with them, among other issues.

Solape (not real name) held her stomach, screaming and writhing in pain in her bed. Her boyfriend, Kolade, paced the length of the room, anxiously waiting for a doctor whom he had called 30 minutes earlier to come and attend to his girlfriend.

A neighbour who just completed her training as an auxiliary nurse, Aunty Nurse, as she is popularly called in the neighbourhood, heard the ruckus and offered to help administer first aid before the doctor arrived. She gave a dose of analgesic to Solape and the pain subsided.

When the doctor arrived, he examined her and couldn’t find anything wrong. Unknown to him, the analgesic had masked the pain of appendicitis and made it difficult to diagnose. He, however, advised that she be taken to the hospital for tests.

Solape ignored the doctor’s advice and decided to sleep it off as the analgesic given by Aunty Nurse had worked wonders. However, she woke up to a worse pain than she felt before and vomited on the bed where she lay. Kolade then rushed her to the hospital where it was discovered that she had appendicitis and it had ruptured.

Solape was lucky to survive the incident but not every victim of the negligence and ignorance of auxiliary nurses in Nigeria lives to tell the story. One of such unlucky cases is that of the young promising singer, Ilerioluwa Oladimeji Aloba, popularly known as Mohbad.

On Friday, October 6, the Lagos State Commissioner of Police, Idowu Owohunwa, named an auxiliary nurse as the prime suspect in the death of the singer. It was alleged that the nurse administered three injections on the singer in his house and this resulted in a series of events that led to his death.

In the light of this context and the various issues that sprang up at the mention of auxiliary nurses, it became imperative to look into the idea of auxiliary nurses as a whole, their use in hospitals, their roles and the difficulties that doctors and other healthcare professionals encounter when working with them.

The rate of unemployment in the country has driven many youths into different alternatives. Some become artisans and while some others establish small businesses, others who have an interest in health work train to become auxiliary nurses.

In Nigeria, auxiliary nurses are mostly young people with basic education who get trained by private health institutions to perform the duties of a nurse. It was also gathered that some auxiliary nurses establish and run health outfits in rural areas without supervision of any kind.

While nurses have to meet certain requirements like attending nursing schools or colleges accredited by the Nursing and Midwifery Council of Nigeria (NMCN), passing the NMCN licensing examination and getting registered with the NMCN, auxiliary nurses simply have to get trained on the job by doctors or nurses for a couple of years.

According to the World Health Organisation (WHO), “auxiliary nursing is a type of nursing that involves providing basic care and support to individuals, families and communities under the supervision of a registered nurse or midwife. Auxiliary nurses are also known as nursing assistants, nursing aides, community health workers or health extension workers in different countries.”

Speaking with Sunday Tribune, former president of the Nigeria Medical Association (NMA), Professor Mike Ogirima, disclosed that auxiliary nurses do not exist legally in Nigeria.

He said: “The term auxiliary nurse was coined by some private practitioners who extorted money from secondary or primary school leavers in those days to train them to perform the duties of a nurse. There is no place for auxiliary nurses in the cadres of healthcare. What we have is health assistants, what we call attendants in those days. Auxiliary nurses do not exist legally.”

Roles and Qualification

Healthcare workers are entrusted with the responsibility of caring for human life and it is essential that they are qualified to take on the task. Given the fact that auxiliary nurses are nowhere near qualified as registered nurses, it raises questions about their roles and responsibilities in a healthcare setting.

Speaking on the roles given auxiliary nurses, Medical Director of Royal Hospitals, Suleja, Niger State, Dr Bamidele Ibrahim, told Sunday Tribune that any task given to auxiliary nurses must be under supervision.

According to him: “Their role is just like that of nurses but they are under supervision. We supervise them; we don’t allow them to do things anyhow. They give injections, they give drugs, and they take the vitals of patients, so, we don’t allow them to do procedures that are beyond their capabilities.

“This is because according to the Nigerian laws, they are not qualified nurses and are not recognised as nurses. And that is why there are no schools for auxiliary nurses. They are just trained by some hospitals.”

Professor Ogirima, who is also the Provost of the College of Health Sciences, Federal University Lokoja, explained that “auxiliary nurses can perform various tasks such as taking vital signs, assisting with personal hygiene, feeding, dressing, mobilising, administering medications, monitoring health status, providing health education and counselling and referring patients to higher levels of care when needed.

“Auxiliary nurses can also help improve access to key maternal and newborn health interventions in low-resource settings by providing antenatal care, postnatal care, family planning, immunisation and management of common illnesses.”

According to Public Health Nigeria, “the main responsibility of an auxiliary nurse is to ensure patients are kept as comfortable as possible. They wash and dress incapacitated patients, feed patients at meal times and help those who have difficulty walking, to get around. They also help the elderly and disabled with going to the toilet. They also assess patient’s health by taking temperatures, measuring weights and assessing respiration levels.

“An auxiliary nurse also performs minor medical procedures and assesses blood pressure levels. She or he will also make the patient’s beds and assist with the general upkeep of the ward. They also work alongside healthcare scientists, assisting them in the identification and treatment of a range of diseases. They also help healthcare scientists with the analysis of blood and urine samples and patient histories. All under the supervision of health care professionals.”

Speaking on the training of auxiliary nurses, a consultant orthopaedics at the Federal Medical Centre, Jabi, Abuja, Dr Ganiyu Aremu, told Sunday Tribune that auxiliary nurses are basically trained by doctors in private hospitals for some time and when they are employed by other hospitals, they are also retrained to adjust to the culture and practices of the hospital.

According to him, auxiliary nurses are trained by doctors in private hospitals and the systems that are peculiar to that particular doctor, the way he does his things and the way he expects people, who work with him, to also do things. So, if a doctor employs an auxiliary nurse who has worked in another hospital, he will have to retrain the auxiliary nurse to the level of how he does his things. The same goes for nurses and doctors. I am a specialist; if I employ a nurse or doctor, I have to train him or her to get used to my style and how I operate.”

Agreeing with Dr Aremu, Dr Ibrahim said training to be an auxiliary nurse is synonymous with being an apprentice. He said: “There is no school of auxiliary nursing. It is private hospitals that train them. Some of them spend two to three years in training. After their training, they get their certificate. It is like an apprentice. They may have the technical skills but they lack the theory to back it up.”

Benefits and Challenges

Despite their lack of qualifications, they seem to take on some important roles in the healthcare setting. Consequently, Sunday Tribune went on to find out the benefits of having auxiliary nurses in the hospitals.

According to Dr Ibrahim, auxiliary nurses fill the gap created by the Japa syndrome where registered nurses are in short supply in the country.

According to him, “the Japa syndrome is complicating things. It has a damaging effect. The nurses who are fresh graduates don’t even apply to work anymore, they write exams and start planning to relocate.

“In private practice, we cannot get the number of qualified nurses that we need. There is a shortage because the salary is not commensurate, it is poor compared to government hospitals. Most of them graduate and do not come to private practices and this is what informed the auxiliary nursing.

“Auxiliary nurses are easily available and the salary is equally okay for their level. I don’t think it has any negative impact because they are always under supervision. They do not do things anyhow. If you employ some registered nurses, they will monitor them. Whether we like it or not, it has a positive impact on the system.”

He added that registered nurses cannot cope in some rural areas where there are no basic amenities like water and electricity. He said most registered nurses will not stay in such an environment but auxiliary nurses will.

However, Professor Ogirima believes that auxiliary nurses are preferred and employed by private hospitals because of cheaper wages. He also added that the solution to the gap created by the Japa syndrome is to train more nurses and not engage quacks like auxiliary nurses.

“The only thing to do to solve the gap is to train more nurses. Let secondary school leavers go through the school of nursing and after three years, they become staff nurses. If they want additional qualifications, they can go for midwifery training and become staff nurse/midwives.

“No government institution trains auxiliary nurses, which tells you that the programme they mount in private hospitals is designed by the medical practitioners to extort them. It is not the best to engage those quacks,” he stated.

Speaking on challenges faced by healthcare professionals when working with auxiliary nurses or employing them, Professor Ogirima noted that the major challenge is that they are not qualified nurses and do not have regard for standards in the delivery of healthcare.

“The challenge is that they have not received any training as nurses, so they don’t know how to keep standards. These are the people that will give injections in private hospitals and they do not understand the principles of sterilisation or antiseptic technique. They go ahead and use instruments or needles that are rusty. They practice with little care for standards. They jeopardise standards for procedures. They are only restricted to the knowledge they have because they are trained by those private hospitals,” he said.

He also disclosed that auxiliary nurses pose danger to the health system because they cause more like diseases instead of treating the diseases.

Dr Aremu disclosed that challenges arise when auxiliary nurses are not properly supervised and that the mistakes they make can also be made by trained nurses when there is a high number of patients.

“The mistake could be in the form of where they give injections. We have had instances of patients developing nerve paralysis from inappropriate administration of injection and adverse drug reactions from problems of either inappropriate dose or not giving the right type of medication,” he said.

He, however, suggested that their role should be minimised and when they perform their roles, they will not be held responsible for what they do right or wrong. The responsibility will be on the person who supervises them.

He also said that whoever is engaging them should know that if anything goes wrong, he/she is the one who will be responsible because they are not trained or licensed.

Dr Aremu added that some auxiliary nurses establish health facilities in rural areas, saying that many of the challenges can be mitigated by adequate supervision.

“There are many challenges and those challenges can be solved by proper supervision and clearly defining the roles they should carry out. It is so bad now that if you go to some rural areas, a lot of auxiliary nurses have private health facilities that they run. That is to tell you how they are not being supervised.

“The various ministries of health should supervise adequately the establishment of hospitals and running of hospitals, do their evaluation and proper monitoring. Such things should not happen but we see them,” he said.

Reacting to Dr Aremu’s claim that auxiliary nurses establish hospitals in rural areas, Professor Ogirima said the auxiliary nurses are in the communities that are out of the sight of the government. He also advised that auxiliary nursing should not be encouraged to do such.

According to him: “They are out of the purview of the government’s eyes. They are there in the communities and I don’t see any difference between an auxiliary nurse and a traditional birth attendant. There is no difference.

“I believe we should not even think of encouraging those groups of nurses because they have not received any training. If you want to be a nurse, go to nursing school. But because they are cheap, they are readily sourced by practitioners and they pay them a meagre salary. So, they engage them to maximise profits.”

When asked if this group of nurses should be written off, Professor Ogirima said that anyone who wants to be a nurse should get trained as a nurse and that auxiliary nurses can be employed by government hospitals as health attendants or assistants.

“If anybody wants to be a nurse, there are schools. If you have your five credits including Mathematics and English, you can even get a BSc in Nursing Science. Another thing the government can do is that auxiliary nurses can be employed by government hospitals as health attendants or health assistants. We have that cadre in the establishment. My suggestion is to encourage those cadres and job schedules to be given to them, not schedules of nurses. I will not encourage private hospitals to train auxiliary nurses.”

Dr Aremu suggested that people who are interested in health work should attend alternatives to schools of nursing like colleges of health technology where the requirements for entry are not high and tuition is affordable, and get trained to become community health extension workers.

“Those that have flair for health work can go through that route and become community health extension workers. That will give them some training on how to administer drugs, where to give injections and all that. They will have some limited knowledge and they can perform better. I have worked with those who trained in colleges of health technology and I can say they are fairly okay,” he said.

Dr Aremu also emphasised the need to be properly trained as a qualified nurse so as to avoid mistakes that could result in loss of life due to lack of training.

“None of the medical associations will support anybody employing an auxiliary nurse. Indeed, the association of nurses and midwives see them as parasites and those usurping their roles. Whoever employs them will be held responsible if they make mistakes, you can’t just employ them without supervising them.

“We are talking about human life. Certain mistakes might be committed and lives may be lost and nobody will want that to happen. I have worked in hospitals where they are employed and I will emphasise that anybody that wants to perform the role of a nurse should go to the school of nursing and be properly trained,” he advised.

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