Zambia - The REAL Africa!

Hello to family and friends following our journey,

Jackie and myself have the privilege to share and guide the journey of 12 young women through this international clinical experience in Zambia. To introduce myself, my name is Jessica Barker - the reason that some of you may not have met me face to face is that I am currently living in Cape Town, South Africa and pursuing my Masters of Public Health at the University of Cape Town. I am also a graduate of UBCO School of Nursing, and was one of the first groups to head to Ghana in my 4^th year of nursing in 2007. As you can see from the blog entries, an international nursing practicum can be a challenging yet life-changing experience. I very much resonate with the student experience, because six years ago... that was me! At the time in 2007, I had never been out of North America, and this was my chance to see another part of the world and grow my nursing practice. In Ghana, I encountered many of the same experiences our students discuss in this blog. I fell in love with the continent, the people, the culture -all of it. What an experience and it totally changed my life path.

Jackie and Jess enjoying some down time in Mongu

Since graduating from UBCO, I have actively pursued my love of teaching, and expanded my global nursing experiences to other countries including: Nicaragua, Zambia and South Africa. The opportunity for Zambia came in 2008, and for six months I came to Mongu, Western Province and volunteered as a nursing instructor at Lewanika School of Nursing. At the time, we were not bringing UBCO nursing students, but the interest in global health and international experiences within the program was growing. I called up my colleague Fay Karp, who as Associate Professor within the School of Nursing, and said ‘Come to Zambia..it would be perfect for nursing students!’ Guess what? She came only a couple months later to assess the site. Our first group of UBCO nursing students came to Zambia in 2010, and since that time we have supervised over 75 students in Zambia. In my view it is a wonderful opportunity to engage with our Zambian colleagues and an opportunity to develop a collaborative exchange between Canadian and Zambian partners. At the core of this program are values of community development, empowerment, capacity building- which translates to truly listening and valuing others' contributions from a grassroots perspective. In my Masters program, I have been consolidating my learning on population health, primary health care, epidemiology, health policy, health system strengthening, and advocacy - with a goal of improving health care in a limited resource setting. I thread this new found knowledge into the curriculum for our UBCO nursing students. These are all issues that are at the forefront of practice in Zambia, and as you can see from our student blogs, are often issues that challenge nurses coming from a Canadian context.

Health care and health care delivery in Canada is not perfect- but the beauty of global health is how the issues that challenge us as a country, can also be relevant in Zambia. It allows students the opportunity to merge and/or draw parallels from experiencing two very different health system settings. The beauty of this practicum is that it allows students (maybe for the first time in their life), to really think about life for people in other parts of the world. These are no longer pictures that you are seeing on a TV from your home in Canada, but these patients and people are now right in front of you. Finally HIV has a face, a story. You realize these people have families, a career, and a life that matters. You are frustrated knowing that their life will be shorter now, because of the constraints facing the health system in Zambia. You are hit hard when you realize the only difference between us and them, is where you are born. Then you think, wow this 31 year old patient that just tested positive for HIV could have been me.

I admire my Zambian colleagues, they are constantly having to adapt in these limited resourced settings. Their ingenuity and drive to advocate for the health of their people is inspiring. They are trying hard and often it is an uphill battle -but they are doing their best with what they have. Many ask me why I continue to come back to Zambia, and my answer is always because of the people, my colleagues. It is also selfish, because as much as people think I come over here to ‘help’, the reality is…I’m the one who is changed. The Zambians are the ones 'helping' me. They are constantly teaching and growing my nursing practice and they challenge me to be a better teacher.

I am proud of how this program continues to grow and proud of each one of our twelve nursing students that have taken on this Zambian experience. To their loved ones back home, you should all be beaming ear-to-ear knowing how they are representing themselves, our school of nursing, and our country. Thanks to all for reading this blog and being our constant sources of support!

~Jessica (+ Jackie!)

Reflection on week 2 at the ART Clinic

Good Afternoon from beautiful Zambia!

This week Lauren and I were at the Anti-retroviral Therapy (ART) Clinic. This clinic has 18,000 clients and provides care for those in Mongu and the surrounding communities. The clinic provides counseling, CD4 counts, adherence support, medications, and follow up check ups.

When looking at how HIV affects the individual’s health, the CD4 count and viral load done. To be eligible for anti-retrovirals (ARVs) in Zambia, the client needs to have CD4 count <350 .="" font="" nbsp="">The WHO has stated that to be eligible for ARVs one needs a CD4 count of <500 font="">. The lower the CD4 count, the more susceptible the person is to infection and illness. The viral load tells how fast the disease is progressing and more accurate picture. The demand is already overwhelming for this clinic and I am not sure how they would be able to support the increase in CD4 count.

So even though client is given the diagnosis of HIV, the client has to wait until the CD4 count is low enough to eligible to receive the ARVs. ARVs are not a cure, however, helps to extend the individual’s life. I have compared the treatment of ARVs to being like receiving chemotherapy or radiation to treat cancer. Unfortunately the clinic has to send viral loads to Lusaka and have to wait for the results. They have worked around this by determining if a CD4 count is still not improving on first line ARVs , then they will start them on second line ARVs while waiting for viral load results to come back in order provide treatment in the mean time. An example of how a limited resource clinic continues to provide the best care and work around challenges.

I have interest and would like to work in public health at some point in my nursing career and really enjoyed my time at the ART clinic. I enjoyed working the with staff and keeping busy in the clinic, however, I would be hit with moments when I reflected on that every face that I had seen (one day 500 clients went through) is the face of HIV. The clients sometimes wait 8-9 hours before getting through the clinic, after having traveled from far distances. One client had come from the flood plains across the Zambezi River, dealing with a hippo that was challenging them and then still had to get to the clinic. This client left at 0400 and didn’t arrive to the clinic until 0800 and was in the clinic until about 1300 for her medications. I thought  about every time I have ever been frustrated with traffic, like when I was heading across Vancouver to get the ferry.

Tuesday it is reserved for the pediatric clients. I started off the day with taking part in the education session about HIV status disclosure. The children want to learn more about the HIV disease, and have a day where they have a picnic and play games. The staff member providing the education is fantastic, she is so passionate and can see how much she puts into her job. I went over to adherence with her and other staff members who were running the adherence department are just as great. They answered all my questions and also took the time to translate and include me in the conversations. In adherence you are to provide counseling surrounding the client’s health and finding out how the adherence is going. It was here that I would see children come in and fill out the paper work and assess how they were managing. I would get caught up in being happy to be working with the children that again I would be hit with a ton of bricks and realize that all these children have HIV. I think of the term “ child poverty” and how it relates to the situation the children are born into.  The child didn’t have a choice to have the disease transmitted to them and have managed to live past the age of two. I have been trying to imagine what it would be like to be a child with a disease that is unfortunately carries a large amount of stigma. I have had to reread our resources many times to try and wrap my head around this complicated disease. Through discussion we talked about how the rash makes it easier to identify the children that are HIV+ and how this contributes to the stigma. We talked about the children that are orphans. These children were at the clinic managing their own ARV therapy. My parents know how I easily forget to take my vitamins at home and to think that this child is managing his or her complicated disease that has changed his or her life forever. I asked about the challenges that the staff member recognizes. These included transportation to the clinic, the clients having money to buy food and the stigma of HIV. Another challenge has been with retaining clients who are deaf, because of the communication breakdown and thinks that it would be good if there was training to teach sign language. Specifically to the children’s clinic day he stated that they do not have toys to help attract the children to come to the clinic and help fight the stigma. It is also important to promote play and give these children the opportunity to be children. I see this being very important when the children already have to grow up so quickly. It  is neat to see the concept of conducting a needs assessment in reality and not just in a textbook. The idea of creating a toy box came from the clinic itself and trying to connect and gain an understanding.

The language barrier can be funny at times. For example in the Art clinic this week I kept hearing “ twin towers”. I sat there just thinking, what are these twin towers are they talking about, is this where someone lives ? and of course New York ran through my head,  so I finally whispered to Lauren asking what about this. We started laughing because they had been talking about 20 hours.

Yesterday the team visited the chitenge tree and bought our fabric to have our dresses made. I would say that we are becoming more comfortable here in Mongu. I had a great experience with the Zambian women in the market today. I had replied the Lozi greeting for the morning and clapped my hands and had the woman in the market laughing and helping me with my pronunciation. I was thanked for trying and was asked where I was working. After telling them about being here with the school and nursing at Lewanika hospital they thanked me for coming and that I am welcome here. It is moments like this that can help take a layer off of the minority label and feel more at ease and see the beauty in this community.  

Off to Save A Life this week with Darien and looking forward to it.

Aileen

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

A New Side to an Old Cliché: our week in a Zambian HIV/AIDS clinic

Off to a great start for our first week in our international practicum! We were placed at the Antiretroviral Therapy (ART) clinic. This is a clinic that treats people infected with the HIV/AIDS virus. HIV is much more prevalent in Zambia when compared to back home in Canada. To put things into perspective, Canada’s prevalence of HIV is 0.5% of the population; in Zambia, it is 14.3%. This clinic alone treats over 18,000 patients and is considered the largest one in Western Province. There are two other clinics close by that also treat a large number of people. On our first day, the clinic saw approximately 500 people!

There are five components to the clinic:

1)   Testing and counseling. Patients are either referred by a Doctor or can come in on a voluntary basis.

2)   Group counseling session, registration, blood draw, vital signs and weight are taken.

3)   Follow-up with the clinician for an assessment and antiretroviral (ARV) drug prescription.

4)   Adherence, which goes over possible drug side effects as well as counseling surrounding safe sex practices and healthier lifestyle choices.

5)   Pharmacy. New patients are usually only prescribed two weeks worth of ARV’s and then have to come in for a follow-up. Usually, patient’s are given 2-3 months worth of ARV’s. A day at the clinic is an all day event…

During the five days we were placed in the clinic, we saw a handful of inequities when comparing to the Western world, specifically with our experiences back home.

ARV’s only became available to Zambia in 2008; Canada has been offering these drugs since the mid 90’s. The Western World is also at the forefront of HIV research and has the newest therapies available to its citizens.

ARV therapy and HIV status is monitored by CD4 counts and viral loads (both are blood tests). CD4 counts monitor how well a person’s immune system is doing, and the viral load monitors where the HIV virus is at. So if a person’s viral load is lower and their CD4 is higher, it means that the ARV’s are doing their job. Both are essential when monitoring ARV treatment. The WHO recommends treatment be started when a patient has a CD4 count of less than 500, if a woman is pregnant, if children are under age five, or if a person is having certain signs and symptoms of the disease. They also recommend CD4 monitoring every six months.

In Zambia, drug therapy is started on patients with all of the above, except, rather than starting a patient on therapy with a CD4 count of less than 500, they don’t start therapy until their CD4 count is less than 350. This means that Zambians can’t have access to ARV’s as fast as other patients in wealthier countries. Basically, they start treatment when their immune systems are lower than the recommended levels. Many patients are not getting their CD4s monitored every six months. Many hadn’t had them done in over a year, and for some, it had been longer than five years. Reasons for this include the number of CD4 machines and trained staff available, as well as issues surrounding patient transportation to the clinic. Remember that Mongu is very spread out with many surrounding villages and it is difficult for many people to travel to the clinic. LGH is also lacking a functioning viral load machine, so this test isn’t even available.

Lastly, ARV’s can come with numerous side effects, ranging from nausea, vomiting, and dizziness, to hallucinations. Back home in Canada, if a patient is experiencing this, drug treatments can be revised or other medications can be prescribed to help counter the side effects. In Mongu, that is not always the case. While ARVs and prophylactic antibiotics are paid for by the government, other drugs are not. Sadly, these drugs are financially out of reach for most Zambians.

            On the other hand, our week at the ART clinic also showed us a positive side of HIV/AIDS care that we would have never experienced in Canada.  The entire week, one of the psychosocial counselors working at the clinic had been asking if he could test me (Darien) for HIV.  The entire week, I had laughed it off and redirected the conversation.  Why?  Being tested would involve a quick prick of my finger, a drop of blood on a pregnancy test-like strip, and a result within 2-5 minutes.  Easy.  But when confronted with an offer to confirm my HIV status, I almost instinctively dug in my heels.  A part of me, a big part, it turns out, was too scared to know.  Even though my chances as a Canadian were 1/50 000 compared to the 1/5 chance faced by any Zambian. 

            On Friday, I finally got tested.  It took two minutes and the result was negative, which came as no surprise.  But waiting for the stupid strip to tell me so was the longest two minutes of my life.  The counselor had been bugging me all week to get tested and my chances were 1 in 50 000. 

            It got us thinking about the brave Zambians who voluntarily come into the clinic to be tested knowing that their chances of testing positive for the notorious human immunodeficiency virus are 1 in 5.  Chances are, they’ve seen someone die of AIDS.  We watched people get tested, and we watched people test positive.  It was heartbreaking.  But as one of the psychosocial counselors explained, acceptance of a “positive life,” as they call it, is much more common here.  Whether a person is living a “positive” or a “negative” life, a Zambian is encouraged to take similar precautions – you are either protecting yourself or protecting someone else.

            This acceptance reveals a stark difference between Zambia and Canada – my hesitance to be tested is a prime example.  Back home, people are terrified of HIV; it’s a “dirty,” “terminal,” “incurable” disease that only “homosexuals and IV drug users” get.  Here in Zambia, there are posters encouraging people to get tested plastered on walls, and patients come in knowing at least a little about ARVs.   In general, myself and Ali included, the Canadian population doesn’t know that the right ARV therapy can allow an HIV+ patient to live a quality, full-length life.

            The HIV counseling office was one of the components that impressed us most so far about the ART clinic.  When a person comes in to the clinic to get tested for HIV, they first sit down with a psychosocial counselor (PSC).  Since most of the sessions are done in Lozi, the local language, one of the PSCs was kind enough to role play a session with Ali and I as patients.  To be honest, we expected a scripted lecture in medical-ese about HIV, AIDS and CD4 counts.  What we got was a compassionate, interactive, informative dialogue in layman’s terms.  The PSC picked up on our learning needs, made sure our questions were answered, and gave accurate, thorough information without judgment.  The PSC is also the person who administers the HIV test.  This seems like a small detail, but by the time it came to administer the “test,” we felt safe, supported, and well-prepared rather than overwhelmed and alone. 

            HIV/AIDS, stigma or no stigma, is a life altering diagnosis.  The long two minutes I spent in limbo and the week that we have spent surrounded by the victims of this disease has shown us that.  While resources are slim and the patient volume is immense, the Mongu ART clinic should be proud of the care they are providing to their HIV+ patients, and Canadians could learn a little bit about acceptance from the brave people of Zambia. 

                                                                                    - Ali and Darien

Zambia 5.0 (5th group of nursing students from UBCO!)

Hello from Zam!

What a whirlwind! We arrived in Mongu March 13^th and time is certainly flying by! The students have blown us away in their ability to adapt in the constantly changing circumstances that Africa throws their way! As you can see from their blog entries this week they were very ‘hands on’ and their level of engagement in patient care and advocacy constantly amazes us.

Jess has been very busy mentoring me into the role of clinical instructor here in Zam (we write this blog together). I cannot believe the level of respect her colleagues here have for her- everywhere we go people are excited to see her face. We have been meeting with several Zambian colleagues and I’m so excited about what the future could hold with this partnership. We are working with the Lewanika School of Nursing, Lewanika General Hospital, and a number of community outreach clinics. I had the privilege of spending Friday morning at the Save a Life clinic and we saw more than 30 patients in 3 hours; I am getting quite skilled at HIV and Malaria testing.

I had a first that I will never forget this week. I informed a 26-year-old woman that she was HIV positive. As I heard Lihana (the nurse that runs Save a Life clinic) counsel this woman about her status I felt every hair on my body rise- it was just a moment that I couldn’t quite wrap my Canadian brain around. The women here are strong beyond anything I’ve ever seen, she did not say more than 5 words, but nodded her head several times.  She has two children and I instantly had to think about the repercussions – her children need HIV testing, she needs to be seen at the ART clinic, and she is single living in a remote village far from the hospital…  How will she manage?

Jess and I spend the days helping out, and checking in on our students on the various wards (not units) they work on! It is full on- I have to stop and remind myself that drinking water is necessary in this + 28 humid weather.

I’ve decided to start a list of things one needs to know before they travel to Zambia in a nursing context: 1) Here you do not start a conversation without asking the person how they are 2) If you are very bathroom shy, do not come to Africa! 3) text messages are SMS’s and they too start with ‘how are you?’ and ‘how is your family?’ 3) Privacy in the hospital is Western world privilege 4) The sunsets and sunrises are worth the trip in itself 5) If you come to Mongu get ready to hear ‘Makuwa’ over and over and over (and over) again – this means white man! 6) The taxi drivers will include a stop to the bank or a visit with their family members on route to your destination 7) A trip to the grocery store takes some needed patience 8) Taping an IV here is called strapping- that has gotten me a few times! 9) The people here want progress, they are hard working and they are making improvements each day- but people always come first- not possessions or meetings 10) And last (for this blog) Construction workers are the same in Africa as they are in Canada- they like to hoot and holler!

That’s it for this week ~ J & J (as our students call us!)

Reflecting on the Woman’s Ward- first week of clinical

The first day on the ward felt like being blinded by a bright light. The orientation, smells, condition of the women was a lot to take in, however, I have grown so much from that initial day and able to see how this floor provides the best care with limited resources.

This week I have reflected on the patriarchy that appears to be a part of the culture. I struggled with the interactions that some of the female staff members and students would have with some of the male staff members. On a particular day, I had witnessed some of the patriarchal behavior from a doctor towards the female nursing students. When the doctor had asked me if this was how I handed gloves to a doctor, without even thinking I replied with saying in Canada we don’t hand gloves to them and went on to explain how rounds work and the role of a charge nurse in Canada. Things were smoothed over and I politely and respectfully provided my point of view. I am a feminist and I have been pushed here several times, and have respectfully kept it to myself as I realize I grew up in a different culture. I think in this moment I was able to be a role model. I did use of my position to show that I can be intelligent, independent and be empowered. I hope that I was able to demonstrate empowerment to the others that witnessed this moment .   

However, even though I have struggled with this, I have the most respect for the women that I was able to care for and work with. These women are so strong and stoic. The women that have young babies are caring for them while on their hospital bed. The woman would have another family member, usually a female, however we did see some men at the woman’s bedside helping to her care. On our first day Shawnel and I witnessed a MVA (manual vacuum aspiration) of an incomplete abortion. There was family planning counseling, but under no analgesic was the procedure performed. I found this very hard be in the room for. I am in awe of how this woman and other women are to keep back from expressing the pain they are experiencing. I just know I would be screaming and this woman was minimally expressing her pain. From that moment and for other patients on the ward I would try to advocate for pain medication. I come from a place where the minute you have pain, it needs to be taken care of and the idea that one shouldn’t be in pain. I realize this and want to have conversations about providing some relieve to promote healing and ambulation. I have learned there is a strong fear towards analgesia because of the fear of addiction. 

This week I had conversations with Jess and Jackie about how I felt like really I wasn’t making any sort of impact or slight change. I didn’t expect to fix or create a huge change, but wanted to be purposeful. I built on our conversations and chose that teaching the importance of a blood pressure. I explained the importance to have a blood pressure and what it can tell you about your patient’s condition. I also demonstrated how to do a head to toe assessment and talked about how it provides a picture of the patient’s status. I hadn’t felt like I got anywhere, but Friday morning I reflected and changed my attitude and mindset. I decided that I would complete tasks and my interactions to be enough. On Friday there were two nurses for approximately 56 patients. While taking a patient to the operating theater I talked with a nurse around the challenges of this ward and the blood shortage. I felt in that moment I was building solidarity, and told the nurse to please put me to work and let me help.  I felt like I helped these nurses that day as much as I was able to and grew further in this experience.  I have learned so much from doctor’s rounds, from the staff and will be looking for ways to contribute back for everything that I have been gaining in this experience. ---- Aileen

Hello Mama Africa!

First and foremost, Mongu is a beautiful place filled with wonderful, welcoming people.  From the moment I entered this town I felt accepted with open arms.  The Lozi people always ask how you are doing and are patient when us, Makuwas, attempting their language. When working on the Female ward with Aileen this week, these characteristics really came to light.

It is very hard, if not impossible, to relate this experience to Canada, but there was one continuous trend that, in my opinion, is universal.  Respecting our patients and allowing them to feel safe in our care should be a universal trend.  The patients on the Female ward were extremely trusting of us.  From day one, they showed us their appreciation through holding our hands, traditionally clapping 'thank you', and allowing us to obtain personal information even through the obvious and sometimes frustrating language barrier.  These patients are in vulnerable positions when coming to the hospital and this is where respect and providing safe care comes into play.  

There are many incomplete abortions on the female ward.  These abortions may be due to the women taking herbal medicines or performing other measures to stimulate an abortion, since having intercourse before marriage is frowned upon.  These women then come into the hospital with severe uterine bleeding and in need of an MVA, which Aileen has explained above.  Furthermore, they are often embarrassed, ashamed, and in many ways ridiculed when they are seen by the doctor (this is done on the ward, by the way, so most patients can hear the doctor getting mad at the patient for stimulating an abortion or having sex without being married).  

Contraceptive use is discussed before an MVA and is also covered by the Zambian government (this is great!).  But again, contraceptive use is not widely used until after an abortion due to the fact that having intercourse before marriage is highly discouraged.  This makes for a complicated cascade, but I believe it could be helped by empowering these women to accept contraception and not making them feel bad about themselves.  By embarrassing them and making them feel ashamed forms an unsafe environment, thus possibly making them refuse going to the hospital or ashamed to take contraception.  I feel that there is already an evident stigmatization of the hospital in this part of the world, which can be detrimental in many ways.  At the end of the day, these women are having sex and we should be supporting them with their life choices and encouraging them to value their health.  

Although I have struggled with this, I have learned so much about the importance of psychosocial care.  I feel that Canadian nursing is very much geared toward tasks and relying on diagnostic tests that we lose touch with the environmental safety and emotional health of our patients.  I can confidently say that I will always remember this week on the Female ward and how it has encouraged me to not only rely on tangible objective findings, but to relate to my patient and motivate them to strive for their own health in whatever way that my look like.  

Thank you to all the staff on the Female ward at Lewanika General Hospital.  Sefula Clinic, here I come!

---Shawnel Macdonald