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.

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.

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.

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.

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?