Sunday, March 30, 2014

Challenging Interprofessional Collaboration on The Women's Ward

        This week we (Sarah & Robyn) were placed on the women’s ward. As starting at any new placement, it’s come to be a struggle to find your role on the ward. It’s a completely different routine as we are used to back home. This probably stems from the fact that there are around 57 patients for 2 nurses. We cannot even fathom how any of these patients would be able to get quality care with a nurse to patient ratio like that. At first, we struggled with the lack of nursing assessments that were performed on the ward, however, how could that even be a possibility? 
Each morning is started off by completing rounds. The doctor goes around to each patient, re-evaluates the treatment, and adjusts medications. The nurse follows them around taking note of what the doctor has ordered for the day. The majority of the time, the nurse was being used for translation purposes & to record the doctors orders -not to provide insight into the patient’s condition or work collaboratively on their care plan. We’ve worked with these nurses and have seen how smart they are and how much they know & can do. This was a struggle for us, because we know the benefits of interprofessional collaboration, and how this can improve patient care outcomes. Back home, we’ve both worked on 6W - a medical teaching unit - where we are looked at as a source of information and insight into the status of our patients because we spend the most time with them. We’ve noticed that this is one of the gaps on the wards here on Zambia that we have tried to model this week. To demonstrate the effect of modeling we have had on the ward we think a story capture it best. 
After our first day on the ward, after completing rounds, we decided who our most acute patients were on the ward and made it our mission to complete thorough and documented assessments on these patients. One of the patients that we had chosen had been admitted with “Hypertension & Vomiting” and had since been unconscious to semi-conscious for the past 2 days. This patient was on a floor bed and being cared for by her daughter - who was a retired nurse. We had already witnessed the doctor perform his assessment on her. He flopped her arms around, tweaked her nipples to assess for response to painful stimuli, and took a blood pressure reading.  Sarah performed a full assessment later on that day - took her vital signs, listened to her heart, her lungs, checked for reactive pupils..... essentially the works. She documented her assessment and then stapled it to the patient’s chart at the bedside. Then next day, while completing rounds, the doctor saw Sarah’ assessment, read it and then asked, “Whose handwriting is this??”. At first, he looked as if he had been challenged or undermined. We both felt a little awkward waiting for his reaction after we had told him it was Sarah’s. He glanced back at the paper, nodded, made a “hmmph” sound and then completed a full assessment on the patient! He even borrowed our “torch” (penlight) to look in her eyes. This sparked the beginning of our relationship with this doctor - he then went on to teach us about the different types of strokes, the effect it will have on pupil reaction, and the part of the brain that is affected based on the assessment. We felt proud after to have initiated this interaction & relationship with the doctor. From here on, we felt so much more comfortable asking questions, questioning his care plans, and discussing treatments & disease-processes with him... He always gave us funny looks, but we think it’s because he wasn’t used to having so many questions being asked of him. Let alone from nurses, from women -and from white women at that. During rounds one day, our instructor popped by and he made the comment to her “They sure ask a lot of questions....”. By the end of the week we had definitely formed a rapport with him - he even fist-bumped us on Friday! 

Both of us agree that although interprofessional collaboration may be lacking during rounds, the fact that rounds took place each day with the doctors was fantastic!  It was so great to see the doctors lay eyes and hands on their patients each day, and it opened up opportunities for the patients to ask questions, report new symptoms, etc. Nursing back home we often struggle with the fact that doctors are not able to physically asses their patients on a regular basis sometimes at the hospital, and seeing the way it’s done at Lewanika really opened our eyes to the possibility. We were both so impressed at the ability of the doctor’s to make a diagnosis with such a lack of resources - no MRI’s, CT scans, or specific blood-work. The physicians really have to utilize their clinical judgement and also trust their instincts. We also saw an increase in the amount of assessments that were taking place by the Zambian nursing students on the ward through their thoroughly documented care plans.  The increase in nursing assessments on the ward could definitely free up some of the doctor’s time that was spent assessing stable patients not requiring daily rounds.  It is evident watching the Zambian nursing students that they are keen on learning how to asses patient status and plan nursing interventions based on their findings.  Overall it was a fantastic experience on the women’s ward this week .  

Sometimes we feel a little lost in our role here. Are we even accomplishing anything? Are we working to help make the Zambian health care be the best that it can be? Are we just “voluntourists” in a glorified role? These are questions that we find asking ourselves on a daily basis... We might not see that we are moving mountains here but we’ve come to realize that the best thing that we can do is model.  Model how we interact with patients. Model how we work with doctors. Model how we perform assessments. Model our critical thinking skills. Through even our small amount of modeling on the ward this week we have seen small changes. They might be individual changes, but that’s where we are at, and we are proud. 

Sarah & Robyn

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