Saturday, 29 January 2011

Back to nursing

Having trained as a general nurse in 1981, I think that these, by now, rather rusty skills, will now come in handy when I am in Ethiopia. So I am getting myself back on the nursing register. Foolishly, I thought that my nursing days were over and so didn't maintain my registration. My advice to anyone thinking of not paying that annual fee to the NMC is "you never know what you might end up doing, so keep your registration going". In order to get my PIN back I have to do at least 75 hours in practice, be signed off as competent in a variety of things, attend a University 'Return to Practice' course and finally pass the academic assessments. Perhaps it doesn't sound like much - after all, you might say, you have to think about patient safety - however, trying to do this whilst holding down a full-time job and planning a trip to Ethiopia is a skilled juggling act. Sometimes those balls come tumbling down.

So yesterday I did my 2nd shift on the ward after a 15 year break away from any hands-on clinical work. A few things strike me about nursing in 2011:
1) There seem to be a lot of 'specialist nurses', who presumably have quite tightly defined roles in looking after things like 'tissue viability', 'stomas', 'manual handling' etc etc. I want to avoid saying 'when I was nursing..... or in my days.....' but just can't resist. So, when I was nursing, 3 years of what I believe was excellent training, equipped me for total patient care. We were trained in numerous skills (including wound care, stoma care and how to 'handle' patients) and had a professional duty to update those skills. Actually, it wasn't so much of a professional duty, although clearly that was important, but we were interested in keeping up-to-date. Being a nurse was something to be proud of and we wanted to make sure that we did a good job.
It is also apparent to me that there is now a  team division; into specialist and generalist nurses. The generalists work shift hours and provide the day-today care, whereas the specialists work 9-5 and float between several wards. Of great surprise to me was the subtle shift to specialists writing their reports in the medical patient notes. Who are they writing their reports for? Are they supposed to be working with the general nurses to improve patient care? If so, why aren't their reports filed alongside the nursing reports? Of great amusement was the specialists nurse's note that said she carried out a wound care procedure under the supervision of a Foundation 1 year trainee doctor. Isn't the specialist nurse supposed to be the expert?

I'm sure that the specialist nurses provide just that - specialist care - but I can't help wondering whether this shift to specialism has not only created an unhelpful division in nursing, but has also left the general nurse de-skilled in certain areas. Patients are whole people and need to be cared for as whole people. Surely this includes their wounds, pressure areas and stomas?

2) Despite the increasing number of specialist nurses, very little has actually changed in the delivery of care. Increasing technology has meant that the many policies and procedures that dictate how every procedure needs to be carried out, can be accessed from the hospital intranet at the click of a button. I haven't actually seen anyone accessing these policies and procedures but presumably they will when they need to.......
One advantage of having such detailed and prescribed care is that nurses are not spending their time writing out pages of care plans - they just print one of the standard care plans off. So they don't even need to think about the care plan. And that's the point. They don't have to, and it seems to me, often don't , stop to think about the plan of care. Now maybe they are just all very aware of what care the patient needs and so don't need to refer to any notes. If they did look at the care plans, they are likely to find that they are very out of date - often being put there when the patient was admitted but never really looked at again.

3) I have been struck by the amount of time that qualified nurses spend on doing things that less qualified people could easily do. Why are nurses filling up the empty boxes of gloves, aprons etc etc, making fresh breakfast to replace the old one left to go cold on the side, cleaning bed areas, and taking dirty laundry and rubbish out? These are just a few things that a qualified nurse spends the day doing.

4) The nursing 'culture' is alive and well. Similarly to doctors who it has been shown learn how to be a doctor (culturised into the role), nurses also learn the culture of nursing. Having had such a long break away form nursing and spent this time in a different culture - the academic culture - it is enjoyable and almost comforting to dip back into the nursing culture.

So as you might guess, my return to practice is full of challenges, but I am thoroughly enjoying these. Thankfully, the nurses on my course and on the ward I am working on are all fantastic and very supportive - this is definitely something I have missed having left nursing all those years ago.

My question now is how different is nursing care in the UK to that provided in Ethiopia?

Sunday, 23 January 2011

Practicalities of visiting Ethiopia

Although our preliminary visit to Ethiopia means that we will only be there for 11 days, we are keen to hire a car for this visit, simply so that we can visit all of the places that we need to in preparation for our year-long trip in october. I want to visit the Wollega university, and in particular, the health school that appears to be there. Mind you, so far, I have had not managed to get a response to my emails, with the last one being returned due a full inbox. So although I am not convinced that I will be able to meet up with many members of staff from the university, I would like to at least see for myself what opportunities the campus holds for a UK academic like myself. Wollega university is about 150 miles from Gimbie and according to the internet, they have a campus at Gimbie. I think this reflects the nursing school that is based at the hospital, although this is far from clear from the website.

So as with any travel arrangements, we look on the internet to book a car from Addis Ababa airport and are astonished to find that there are very few companies that hire cars in Ethiopia. Indeed, it seems that just 2 companies offer cars from Addis and neither of these are easily accessible via the internet. this doesn't bode well as one of the plans for our October trip is to potentially lease a car for the year. It seems that this will not be as easy as we had anticipated. The reality of getting by in Ethiopia is beginning to set in.


In 3 weeks time we will be flying to Addis Ababa to start our journey to Ethiopia. Unlike Dervla Murphy, who travelled around the country on foot and mule, we are planning to obtain some wheels for use whilst we are there. So yes, we appreciate that some level of 'roughing it' will be necessary, but we are constantly looking for ways in which we can make things more tolerable. After all, a year is a long time for a faranj (foreigner) in Ethiopia.

Key to our preparations are obtaining a mosquito net and a mattress cover, both items being necessary to reduce the number of bugs from feasting on our tasty western, and right now, delicate bodies. There is also a fair amount of reading to be done too. In order to make the most of the trip, I need to understand how the health system actually works across Ethiopia. My extensive reading tells me that large sums of money, much of it donated through the United Nations Millennium Development Goals, have been invested in an attempt to reduce poverty by 2015. One of the goals focuses on reducing maternal and child mortality. So it seems that a series of 'Millennium villages' have been identified to receive funds from the United Nations to help them set up systems that will meet the millennium goals. So in response to the goals surrounding health improvement, the health extension worker program has been set up in collaboration with the Ethiopian government. The health extension workers are trained in health care and are based in the villages (kebeles). They work with families within the kebeles to improve the health of the community. They also work with 'Voluntary community health workers' who are also based within the kebele and who demonstrate the positive health effects that can be gained from following the advice of the health extension workers.

In addition to the community health programs, there are government and faith hospitals. There may be more but so far, I haven't come across them. It's difficult to determine how well either of these hospitals function or the extent to which they are able to treat the population, but this will be something that we will explore when we go out in a few weeks time.

So that's a summary of health care as I understand it. Perhaps my perspective/understanding will change as I see the systems first hand. For now, all I have to go on is a lot of policy documents published by various organisations involved in improving the health of developing countries.