Sunday, December 12, 2010
Nursing in Tanzania:
It is hard to know where to start with this blog... as there is so much to tell, therefore I think there will be several blogs relating to Tanzania; The main focus of the trip was to take 20 nursing students from five different universities to experience nursing in Tanzania. My first impressions were biased with a preconception of what things would be like, having already lived in Africa, however some things still were confronting and the total lack of resources, water, infra-structure (in rural areas) and medication still came as a surprise:
The process through customs, immigration is the usual for any African airport, slow, hot and humid, confusion as to which forms to fill out, eventually we all got through.... the main currency for Tanzania is shillings..... 1000.00 approx for each $1.00.... we changed some currency and got some local sim cards for our phones, we were met at the airport which was fantastic.... we were all bundled into cars and buses, with our luggage perched preciously at the back of the bus. Our hotel was about 35 mins from the airport, the first thing that struck me was the amount of cars on the road.... it did not take long to realise that they all drive like lunatics.... it was equal to Egypt which I thought have the worst driving in the world. There were hundreds of people milling around, over crowed buses and many street markets......
Health care in Tanzania is dependent on social status and level of income is the most predominant social determinant of health for people. This means access to clean water, sufficient food and reasonable health care. Health care access is further compromised due to issues of geographical location and distance to services as well as lack of resources and technology. It was interesting to note that everyone has access to mobile phones even when electricity was not available.
We arrived at our hotel ...... pleasant, clean, small, friendly staff.... the first thing I noticed was there was no bar fridge.... now I know what you are thinking....no not for alcohol... I wanted a cold drink of water.... alas this was to be one of my biggest complaints.... a must in a hot humid country....the availability of cold water and tea and coffee making facility.... minor things really, just shows how spoilt I am. Every day began at 0530... the bus collected us at 0645 to get us to both hospitals..... we would split into two groups, two supervisors and 10 students in each hospital: one to a private hospital and a government hospital.... then the following week we would swap. Mine was the government hospital first.... this was a baptism by fire.... it was a culture shock for all, I was a acutely aware of how the students would be coping, sights, smells, queue’s of people, sad hollow eyes watching our every move....we stood out like beacons in our stark white uniforms; at times I felt like the fish in the fish bowl..... Intruding into the lives of people I could not really make a huge difference to....We would attend the hospital handover, all given in English we would then go to our allocated wards.
I had to focus on the task at hand..... once orientated to the ward we would begin to assess the situation and decide how to move forward.... each ward had a notice board which listed the 10 most common disease and drugs used, together with the tasks for the day: There was no surprise to find No 1 condition in the medical ward was HIV (there are medications and treatments for HIV which was good to see), I learned about the finger test for HIV.... great idea quick and efficient, next condition was Malaria, hypertension, anaemia and diabetes: each ward (medical & surgical male and female) consisted of approx 30 beds, sparse furniture, a single sheet on the beds and some ceiling fans, however the wards were stifling hot.........patients bought in their own food and water; sometimes it was hard to know where to start.... so often I would get students to take vital signs, as this was something I knew they could do well and would start the two way conversation... however our Swahili consisted of “Jambo” – Hello, or “ Hujambo” – how do you do, “Jina langu ni......Pauline – my name is....
The nurses work very hard and are short staffed, often 1 RN to a ward, a couple of student nurses and nurse assistants; doctors milling around, completing ward rounds, barking orders, nursing assistants scurrying around to get tasks completed. There was often only one oxygen cylinder and the ethical decision would be who needed it the most... and sometimes someone would come urgently from another ward requiring the oxygen cylinder ..... what do you do?
The sister's desk:
The drug cupboard was sparse, patients are ordered medications and it is a pay as you get service.....the students coped remarkably well.... all equipment used for patients are paid for by the patient, such as IV cannula’s, drips, catheters, tests etc, everything we take for granted here.... it really makes you appreciate the excellent health care service we have.
We witnessed some interesting procedures and dressings, at times did some teaching as well as sharing experiences and ideas.... it was an interesting journey: documentation, nursing notes, filing cabinets, policies were all nonexistent in the literal sense.... there were two cardboard boxes... marked “discharge notes” a stark reminder of where we were....... Pain seemed second nature to patients....as well as lack of dignity and privacy due to overcrowding and lack of resources..... the hard working underpaid nursing staff and health workers, were not well respected......they do the best they can in these harsh conditions, always with a resolve that things would get better. Also acutely aware of how the situation must look to us the ‘foreign nurses’ apologising for the bad conditions and stating they just do not have enough staff or resources to treat all these patients.
I was amazed at how long people wait to see a doctor or nurse; they have walked for hours and sit patiently in the sun until they are seen, with not a word of complaint.... just happy to be seeing someone and getting some treatments. Our challenge was often to think of cheaper effective ways of treatments, dressings etc choices of medications were limited to bare essentials.......families assisted with patient care, feeding and bathing.......traditional medicines were popular and the stigma of HIV was an issue: I was surprised to see that bowel obstruction was very common – top 10 surgical conditions were: Intestinal obstruction, peptic ulcer, pyomyocties (infection of the muscle), hernia, haemorrhoid, hydrocele, osteomylitis, burns, diabetic wounds, and motor vehicle accidents (no surprise there with the driving we witnessed).
The nursing system is three tiered; enrolled nurses (2yrs training nurse/midwife), registered nurse/midwife (degree course 3yrs), diploma registered nurse/midwife (3yrs or 1yr after EN course): nursing assistant (2yrs – can go on and do diploma RN 3yrs); a diploma RN/M can go on and complete the degree course 3yrs – equal to 6yrs: Their scope of practice is wide and varied........the medical system is equally complicated: from medical assistants to degree MD’s. The graduation I attended had only 10 degree RN/M’s, 20 diploma RN/M’s and 40 Doctors graduating....... nursing is not considered a prestigious career, parents try to discourage their daughters from doing nursing if they are going to do a degree.......nursing assistants and diploma nurses usually complete form 1V (equivalent to year 10).
The question I ask is how do we make a difference? Some of the students who travelled will travel again, they have all be touched by the experience, maybe two or three will go back to Africa and help make a difference; I think you need to stay in one area for a two – six month placement and introduce structures for change; working alongside our fellow nurses exchanging ideas and promoting change: providing mentorship, support for the new students, therefore providing for the future..... Fundraising for essential equipment (gloves, alcohol gel, fob watches, thermometers etc); now that this will be an ongoing project I am hopeful that we will be able to make a difference in some small way:
On our last day we met four first year nursing students, all straight from school, they were so young, full of enthusiasm, our students took them under their wing and taught them vital signs, it was delightful to see, gave them some text books, our equipment, stethoscopes, thermometers etc... and we wished them well. I have promised to keep in touch with one student and provide some mentorship from a distance. If I am to return I will ensure to follow her up.........This has been an incredible journey for me and I will be forever touched by the courage of the patients I have met and for some of the brave nurses I worked with....... I am eternally humbled from the experience.......I have met some fantastic students who are know RN’s and also have made special friends with the other supervisors from our trip........partners in crime.......next blog..... Midwifery!
Good luck to all my students (now RN's)as well as the new students starting....life is a continuous journey which we are all learning.....