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The Role of Patient Guardians in an African Hospital

9 Jun, 10 | by John Offen

Like everything else that I come across in Africa the hospital seems full of contradictions.  The resources are scanty.  There are insufficient nurses, and few doctors, the medical function being carried out by clinical officers who undergo 3 years of training for the role.  Many are excellent, others less so.  Patients come to hospital with a guardian (normally a relative) who performs much of the basic nursing care.  A smoke filled communal cookhouse just outside the hospital, and a small market provide facilities for the guardian to prepare food to be carried in to the patient.  Often the relative sleeps on the floor beneath the patient’s bed.  However, on the ward I work on there are often more patients than beds, the less fortunate being assigned a mat, or blanket on the black concrete floor.  Lines of ants and other assorted arthropods roam largely unchallenged, and children crawl or toddle between the sick.  Some patients are extremely well cared for by their guardians, but others appear dirty and unkempt.  Perhaps the guardian too is unwell – so many in this country have AIDS or TB.  I am told that many of the patients and guardians have travelled long distances to get to hospital, and their absence from home can have dire effects for the family and home they leave behind, as crops go unattended, and a carer for the young or elderly is absent.  A nurse may have 40 or 50 patients to look after, so is completely reliant on the guardians as part of the system, making the nurse’s role very different to the western one.  But amid these scenes, which can be rather shocking to the western eye, the African spirit of hope and endurance survives.  Here the patient will receive much needed medicines and treatment for their complaint, in a country where rural health care is still largely provided by witch doctors.  The staff, in their pristine white uniforms, are mainly professional and committed to their work.  Through the long hours of pain and adversity, the guardians bring companionship and a link with home to the patients as they wait together and endure as only Africans can.

Nursing College Malawi Style

7 Jun, 10 | by John Offen

I have come to Malawi with two fellow students, and we are staying in the nursing college with all the local nursing students.  The buildings are surrounded by grass, avocado and mango trees and the campus is a twenty minute stroll through lush undergrowth from the compact town centre with its market brimming with fresh local produce.  The buildings are in a state of disrepair.  There are three toilets in my block, two of them do not work, and the third has no seat, or lock on the door.  Cockroaches scuttle noisily across the floor.  The shower is an open pipe suspended from the wall.  The hot and cold taps trickle equally cold water, and at times no water at all.  We hand wash our clothes and uniforms in concrete sinks where we also wash up, and prepare vegetables.  Food will not keep here, and there is no refrigerator, so I buy it daily in the market, cooking on a small spirit stove in my room.  This is to be my home for the next few weeks, and I soon get into the rhythm of rising at 5am before it is too hot, and eating a breakfast of bread, peanut butter and bananas before heading off to the adjacent district hospital.  The local students are an attractive bunch; noisy, laughing, and prone to bursting into song, and the girls colourful wrap around skirts, and all the bright smiles counteract any drabness of the accommodation.

Student Nurse in Malawi

19 May, 10 | by John Offen

For my elective placement I have come to Malawi in Sub-Saharan Africa.  I have never been to Africa and do not know what to expect.  My aims are to experience first hand the health care system in a developing country, see what place evidence based nursing has here and, of course get to know the people and the country.  What can I say about Africa?  Exasperating, hot, shocking, addictive, religious, sad, joyous, friendly, corrupt, dangerous, poor in purse but rich in spirit….I could go on.  No amount of reading can prepare you for Africa.  Like many of the western visitors I meet whilst I am there, I am simultaneously appalled by it, and yet love it.  Africa as they rightly say gets under your skin.

Calm

5 Jan, 10 | by John Offen

The Emergency Department is not like I imagined.  It either seems to be full to bursting point, or almost empty; the patients never come in a steady flow.  The nature of the complaints varies in a never ending cycle – the Friday night drunks, the Sunday morning sporting injuries, the early morning chest pain.  There is no panic; an air of calm professionalism pervades the area as the team of doctors, nurses, ambulance staff mesh like the gears of a well oiled machine.  I am impressed by the mutual respect that the nurses and doctors seem to hold for one another that I have witnessed so rarely in other clinical areas.  I like it.

Dead!

7 Dec, 09 | by John Offen

The registrar with a young medical student in tow wore an undecipherable expression on his face.  “Are you looking after the patient in cubicle two,” he enquired.  I acknowledged that I was.  “Well I think you might have closed the curtain,” he snapped.  I evidently looked confused.  “Well she is dead,” he said bluntly.  A rock landed in my stomach.  My patient was dead and I hadn’t noticed.  Worse still her daughter was sitting at the foot of the bed oblivious to the unexpected demise of her parent.  I raced into the cubicle, my worst fears realised as I gazed at the half open, lifeless eyes, the ashen skin, the head tipped slightly back in an attitude of everlasting peace.  I touched her hand wondering if the body had gone cold.  As I did so she opened her eyes fully.  “Could I have another blanket dear,” she said.

Emergency Department Initiation

16 Nov, 09 | by John Offen

My eagerly anticipated placement in the Emergency Department is about to begin.  It is 7 o’clock in the morning, I am a bleary eyed and apprehensive as I make my entrance into the department for the first time.  A central nurse/doctor station is surrounded by rows of curtained cubicles through which I can discern the recumbent forms of patients with conditions unknown.  I feel like an impostor masquerading in my freshly ironed student uniform.  I look around me hoping to catch the eye of a passing nurse to whom I might introduce myself, and instead find myself beckoned into a cubicle by an elderly gentleman who needs the commode.  A moment of panic sweeps over me.  I do not know what is wrong with him – should I get help?  Will this be seen as a lack of confidence?  I decide that I am not happy with the situation, and help arrives.  As the man sits on the side of the trolley, his eyes roll up in the sockets and he collapses, shaking.  We manage to get him back onto the trolley, and rush him to the ‘resus’ room where he recovers and I reflect on what might have happened if I had ‘gone it alone’.

Confidence Intervals

6 Nov, 09 | by John Offen

It is well recognised that many students and qualified nurses alike struggle to get their heads around statistics.  Confidence intervals are essential to understanding nursing research, but can instil feelings of blind panic in the uninitiated.  Like so many technical concepts they are intimidating when you don’t understand them, but not so difficult once you do.  So what does it mean when a study reports that those receiving a treatment are twice as likely to be cured as those in a control group who do not receive the treatment CI95% 1.7 – 2.2 ?.  Nursing studies take place in the real world, and the way individuals respond to a particular treatment or the precise way it is applied will vary.  Researchers try to minimise the differences, but these so called ‘sampling errors’ are still inevitable.  In a study including few participants this could result in a confusing spread of results.  The treatment might work for individual A, but not for individual B.  So what is the true effect of the treatment?  When large numbers are recruited to a study, we might begin to expect that the average treatment effect represents this true effect.  In fact the larger the number of participants, the more certainty we can have about the accuracy of the result.  So how accurate does a study need to be before we are prepared to claim that the results found are valid.  Most researchers consider a finding to be statistically valid if they can be 95% certain of the result.  In practice this means that, rather than quoting a single figure for the effect of a treatment, the authors of studies specify an interval within which they are 95% certain that the true figure lies.  In this case they claim that they are 95% certain that the true figure lies somewhere between 1.7 and 2.2.  As the lower estimate of effectiveness of 1.7 is still well above 1 (if it were 1 the treatment would be of no benefit; if it were below 1 it would be harmful) we can say that we are pretty confident that the treatment is effective. 

 

So I think I understand confidence intervals, and I am 95% confident that my own explanation above is more or less what it is all about.  But perhaps one of you statistically minded people can explain to me what is so special about the 95% CI that has made it so standard across nursing studies.  This de-facto acceptance of an apparently arbitrary figure troubles me.  The community seems to be happy that an odds ration of 1.1 – 1.4 95%CI demonstrates a result that favours treatment, whereas the same study could show say 0.9 – 1.5 97%CI and it would presumably be rejected on the basis that it includes values of 1 and below.  So why is 95% so pivotal and should we feel happy to jump out of an aeroplane 95% sure that the parachute will open?

Venous Leg ulcers

13 Oct, 09 | by John Offen

It would be easy to conclude, as I come to an end of my community placement, that the majority of people over the age of 75 have at least one venous leg ulcer.  Mr O’Leary was no exception – in fact his was particularly painful and had so far resisted all attempts to heal.  Like so many of the older folks in the community, he suffered the pain stoically.  As he squelched his way into his living room for the daily bandage change, I glanced at the exudate stained leather of his shoes and the soggy mass of  bandaging and was reminded of the embarrassment endured by these patients.  Mr O’Leary smiled warmly, gently rolling his fingers in Parkinsonian rhythm as he enquired after my health in a soft Irish lilt.  I desperately wanted to find a way to promote healing, and started searching for any hints in the research literature.  It surprised me to find that until the 1990s, although the UK Department of Health knew that a major proportion of community health expenditure went into treating leg ulcers, it was not known how much that was, neither was the prevalence of leg ulcers known, nor what treatments were being used and whether they worked.  In fact little was known at all.  A systematic review of available research was commissioned for the first time to try to answer these and other questions about leg ulcers.  The results were not encouraging.  The majority of the questions remained unanswered or where there were answers those answers were unclear.  I realised that nursing research has a place in identifying further research needs as well as answering clinical questions.  Fortunately what has been described as an ‘evidence desert’ spurred the NHS into funding a suite of systematic reviews of wound care in 1997.  It is now widely accepted that compression bandaging is the main treatment for venous leg ulcers (Cullum et al 2001), and that no conclusive evidence favouring any particular dressing beneath the compression bandaging has emerged (Palfreyman et al 2006).   Unfortunately Mr O’Leary was not able to tolerate significant compression, and seldom remembered to elevate his legs to aid venous return.  I had no Panacea to help him, and it was clear that we still need further research into this area.  ‘I’ll see you at the same time tomorrow Mr O’Leary’ I said having completed the dressing.  What was my next visit?  Oh yes, another venous leg ulcer.

 

 

Cullum N, Nelson EA, Fletcher AW, et al.. Compression for venous leg ulcers. Cochrane Database Syst Rev 2001;(2):CD000265

 

Palfreyman SJ, Nelson EA, Lochiel R, et al. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev 2006;(3):CD001103

 

 

Management Speak

1 Oct, 09 | by John Offen

It is hard to ignore the politics in nursing.  Every time a qualified community nurse leaves, they are replaced by an untrained Health Care Assistant.  What is going on here?  I do not want to do HCAs down, as many of them do a superb job, but if the job can be done as well by an HCA as a staff nurse, then what is the point in spending three years studying and living on a student grant.  Are the accountants taking over primary care?  Do ‘they’ not realise that carrying out nursing interventions requires more than mechanistically following a care plan.  A few days ago we all trooped to the hospital to listen to the senior manger explain how primary care is moving to a commissioner -  provider model.  Now having been a manager myself in a previous life, I have more sympathy than most for these unfortunate, overpaid individuals, but their talk of corporate identity, metrics and strategic positioning was a real turnoff for us clinicians.  “Tesco,” lectured the speaker, “can sell holiday insurance, mobile phones, in fact almost anything.” The bewildered nurses gazed at each other as the quagmire of mutual misunderstanding between speaker and audience widened.  They had signed up to care for sick patients, were they to sell insurance?  “We must all review our strategic marketing position,” burbled the manager from another planet, but it was too late, the audience was lost.  “We must leverage our core competencies to create a paradigm shift,” she pleaded faintly. To be fair, she had little hope from the start.  The majority of nurses, I believe, nurse because they care about patients, and have no wish to become business savvy; it is incompatible with their approach to patient care.  If we must run like a business, so be it, but nurses should focus on what they are trained for and do best, and accountants should allow them to do so.

Starting my community placement

22 Sep, 09 | by John Offen

This morning I am starting my placement in the community; working with district nurses in local rural villages.  I am really looking forward to it, and it makes me realize that I have actually been a bit disappointed with some of my previous placements.  Like any good nursing student, I have reflected on this surge of renewed enthusiasm, and this is what my introspection has revealed; I have a horror of ‘doctor’s handmaid’ nursing, and it appears that despite the modernisation of the nursing profession, there is still a fair bit of it going on.  I feel that evidence based nursing has the potential to help guide the occupation away from this approach to become an independent, and mature profession.  What excites me about district nursing is the long tradition of autonomy and independence in decision making.  Perhaps I will miss the buzz of a busy ward, but I am relishing dealing with one patient at a time, seeing them in their true environment, and getting to know them as people.  No doubt the reality will not turn out as I hope, but for the moment allow me to enjoy feeling positive, and to savour getting away from the interminable assignments, and get my suitably gloved and decontaminated hands dirty doing the real job of caring for people.

Evidence based confessions of a student nurse

Evidence based confessions of a student nurse

John Offen on evidence, ignorance, triumph and tragedy in student nursing. Visit site

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