CLEAVE

"Grief is not a disorder, a disease or a sign of weakness. It is an emotional, physical and spiritual necessity, the price you pay for love. The only cure for grief is to grieve." Earl Grollman

Since the last blogpost things have been quite challenging. I have had to do a lot of introspection. More intently  into the parts of me that I avoid exploring. Using the word arduous would be an understatement. I have experienced a lot of grief in different spheres and this had led me to try learn and unlearn from my previously held misconceptions. From this I have learnt  three main lessons. These are;

Lesson 1. Grief is personal

"Nothing that grieves us can be called little; by the external laws of proportion a child's loss of a doll and a king's loss of a crown are events of the same size." Mark Twain, 'Which Was The Dream?'

In our setup, grief is synonymous with loss of a loved one. However, that is propaganda. in my experience grief has been

1.  Walking past a friends gate and wanting to call but suddenly realizing that she is deceased. 

2. Watching my classmates graduate before me due to unforeseen circumstances.

3. Witnessing a friend achieve a goal yet nothing is forthcoming for me.

4. Loss of relationships... and so forth, in summary it has been a lot

All this scenarios gave me the same exact feeling. It was a feeling of great physical and emotional distress.

Lesson 2. Grieving is a process

Several theories have been developed to try explain grieving  for better understanding. The general conclusion is that grieving is indeed a process and its not linear. Their is no specific timeframe that guarantees things get easier nevertheless understanding what one is going through is the beginning of moving ahead. 

Lesson 3. It is inevitable

A not so fun fact is that at one time or another grief must befall us .

as I conclude  all this experiences have led me to have a better appreciation of Arthur Goldens words “Grief is a most peculiar thing; we’re so helpless in the face of it. It’s like a window that will simply open of its own accord. The room grows cold, and we can do nothing but shiver. But it opens a little less each time, and a little less; and one day we wonder what has become of it.”

References

Hamilton I. J. (2016). Understanding grief and bereavement. The British journal of general practice : the journal of the Royal College of General Practitioners, 66(651), 523. https://doi.org/10.3399/bjgp16X687325

RECIPROCITY

 “What is tolerance? It is the consequence of humanity. We are all formed of frailty and error; let us pardon reciprocally each other’s folly – that is the first law of nature.”Voltaire

Just as there many facets to the lives we live so are there many facets to human emotions. Hospitals are multifaceted; in one room a family is celebrating a new baby who has been born, news of a full recovery of a family member while in the adjacent room, a family is grieving for they have lost a baby/pregnancy/parent/partner. You get the gist, right? The common denominator is a healthcare team trying to manoeuvre all this simultaneously while not wishing to display the roller coaster of emotions they might be going through. This leads to mental, emotional and physical fatigue. To cope most health workers find some really dark humour in unpleasant situations.  What some organizations and people outside our field forget is that we are humans with real emotions. We get angry, we get sick, we get frustrated, we get sad and we get overwhelmed among other emotions and feelings. We are human beings with emotions and blood running through our veins.

A couple of years ago I received a 4-year-old girl as an emergency while working in the Emergency department. Her eyes were jaundiced, her abdomen very distended, her skin very dry and itchy and when she cried there were no tears. For us that meant she was very dehydrated and whatever health issue she had grossly affected her liver. The team was all hands on deck and we did all we could but unfortunately, she never made it. The child's mother was informed and when I took her to view the body, I got overwhelmed. My throat felt tight, my eyes became glassy and I felt faint so I got a colleague to stay with her and quickly excused myself. I needed to step away immediately. I went to the farthest room I could find and tried closing the door not sure if I fully did and just cried my heart out. You know the ugly cry we all experience every so often. My heart felt broken I just couldn't make sense of it all. It was a hectic shift so as we cared for the emergency other outpatient patients continued to stream in. I must have stayed away for quite some time trying to compose myself when I had someone walk in. I was still whimpering behind the curtains and so I was quickly approached. It was a friend and he just stood there reassuringly periodically asking how he could help. I did regain composure and I walked out ready to face the next patient. I went back to the nurses' counter and the first thing that happened was a middle-aged man approaching me asking "Are there no doctors and nurses to attend to me just because of a so-called emergency." I was so irked but as expected I didn't reply as I wished. My generic response was" Apologies for the delay you will be attended to soon." As he existed we had a quick chat and educated him on what the ED is all about and what it means when a special code is called out.

It was a night shift so the next morning I analyzed the events and realized that both patients and health workers want to feel heard and appreciated but there's occasional ignorance in both parties to a large extent. For hospitals, a lot of emphasis is placed on short turnaround times but often it is not a common reality due to various factors within and beyond human control. Other times it is a very unhealthy mantra which states that a patient is always right. For patients, it is the belief that health workers should always be stoic.

 So how can we do better for the sake of humanity

1. Build awareness among those around you

Have TV monitors/pamphlets displaying basic information that's relevant to the patient groups at hand. 

2. Manage expectations

Language is a tool we often dismiss yet it can break or build relationships. Talk to the patients don't dismiss them, keep updating them. Institutions should have a program that serially educates personnel on better communication among themselves and with patients.

3. Keep evaluating institutional values and policies

There is a lot of value in having staff who are well cared for and prioritized. Physical, mental and financial support goes a long way to making staff feel valued and that's the perfect recipe for the provision of quality care.

4. Stop being self-centred

It's not always about you . There is more to life than you as one person 

In conclusion, “An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.” Martin Luther King Jr.

UNFILTERED

 "Your transparency will lead to other people's transformation."Trent Shelton

If there is one excellent lesson life is teaching me is that life is a journey, not a destination, wisdom does not come with age and in some instances, even the most intelligent person can be a dumb***. Yes, you read that right! Life has a way of evening out the playing field and I see this in my everyday practice. Wondering what I am going on you will understand as soon as you read through this post. 

As a young nurse( young is relative) I was always fascinated by patients who presented to the hospital with complications from poor treatment and lifestyle adherence to managing their previously diagnosed conditions. To give more insight here are a few examples a patient on TB treatment who had deteriorated to treatment failure directly as a result of noncompliance, a hypertensive patient who ended up with a hemorrhagic stroke because after diagnosis they stopped treatment when their symptoms abated,etc

I was well educated but relatively naive to the school of life so I had a very utilitarian way of thinking when it came to chronic illness. In my mind you got sick, you got diagnosed you got healed or you managed to maintain your quality of life. Well, this was how I had been. I have had my fair share of hospital visits by this time and honestly ninety percent of the time I tried to follow through. Notice that I said ninety percent. So one time I asked one of my then patients what hindered him from drug compliance and let me tell you on this day I learnt a lot. This then led me to be asking these questions what are the challenges you are experiencing with treatment or with the diseases that are currently under management.

I
would write a whole essay on this but here are a few examples.

1. Costly drugs or recommended treatment modalities 

While in placement in a rural facility, I met an elderly lady who had been diagnosed with hypertension. She had used medication for a month but then stopped because she could not afford her treatment unless her children catered for it. However, they were also unemployed so that was presently an impossibility.

2. Lack of understanding of the prescribed treatment

Still, on the aforementioned lady, she thought the medication she had been prescribed was for a few months and was only to be taken when she felt her blood pressure was elevated. This for her was whenever she developed blurry vision or swollen legs.

3. Limited knowledge of the implications of the disease process to their everyday life

One time I met a patient who had developed severe anaemia during pregnancy and she never followed up on her appointments. On delivery, she was in severe heart failure. She reported that she didn't know anaemia may lead to such severe symptoms or complications.

4. Stigma and discrimination

A young lad in his first year at the university campus was always in and out of the hospital with diabetic ketoacidosis. On his third visit, he revealed to me that he was experiencing challenges administering his insulin in a timely manner because he was often around his peers and was previously taunted when he administered it in their presence.

5. Unavailability of the drugs

Despite the development of an essential drug list by MOH patients always decry of medication unavailability.

6. Lack of continuity of care

One time a middle-aged lady with irregular bleeding told me she didn't know she was supposed to be reviewed after the completion of treatment. On her return visit the bleeding had been ongoing for about a month non-stop as she was waiting to see if it shall get better as it was not as heavy as when she sought treatment.

7. Personal preference

A patient once came in with a failing liver because he got diagnosed with an infection and he preferred herbal supplements as an alternative to the medications prescribed. 

8. Infomation overexpure

Often we find patients or caregivers who have a lot of information but not necessarily the correct treatment information. For instance, a young female presented to us with a history of irregular menses on further probing I learned she had using combined oral contraception to change her cycle dates as per need for over a year.

9. They felt disconnected from their care providers

An elderly patient shared with me that he has a challenge using medications prescribed by anyone younger than his sons. His youngest son was around forty at the time. He reported that the provider was always either on his computer and hence felt the provider was inexperienced to give him quality care. Unfortunately, on following up I learnt he had not been informed it was a paperless facility and he had never been in one.

Now before you draw assumptions it's important, to be honest. I find it challenging complying to treatment. I am very diligent at my worst but immediately I start feeling better I am more inclined to skip a dose now and then and at times even stop treatment prematurely. Being a health worker doesn't make me immune to this challenge as I  become more transparent on this I'm learning that guarded exposure to patients can help them make better decisions and do better for themselves,. So if like me you are trying to be a better health provider learnt to ask obscure questions. Life is like a coin. pleasure and pain are the two sides. Only one side is visible at a time. But remember the other side is waiting for its turn.

If interested to read materials around this area look up the resources below

Faronbi, J. O., Faronbi, G. O., Ayamolowo, S. J., & Olaogun, A. A. (2019). Caring for the seniors with      chronic illness: The lived experience of caregivers of older adults. Archives of Gerontology and            Geriatrics, 82, 8-14. https://doi.org/https://doi.org/10.1016/j.archger.2019.01.013 

O’Donnell, A. T., & Habenicht, A. E. (2022). Stigma is associated with illness self-concept in     individuals with concealable chronic illnesses. British Journal of Health Psychology, 27(1), 136-158.     https://doi.org/https://doi.org/10.1111/bjhp.12534 

Sarker, A. R., Ali, S. Z., Ahmed, M., Chowdhury, S. Z. I., & Ali, N. (2022). Out-of-pocket payment for     healthcare among urban citizens in Dhaka, Bangladesh. PloS one, 17(1), e0262900. 

IT IS WHAT IT IS

“It’s not like I planned it. I never woke up from some rosy dream and said, “Okay, world, today I’m gonna spaz.” Shannon Celebi

A few years ago a female patient was brought in unresponsive. She was a high school student who had passed out during the second term final examination. According to the teachers, she just saw the examination paper and fainted. First aid was done but there was no response hence the teachers thought it best to bring her to the hospital for further evaluation. Our initial physical assessment was unremarkable. Her vital signs were all within normal ranges and when one tried to assess her pupils she would forcefully shut her eyes. Our immediate conclusion was hysteria. Was it an appropriate diagnosis? I will let you be the judge. After about an hour of observation, she immediately got up. You must be wondering what worked? Well, a cotton wasp laden with chlorhexidine was brought to her nostrils and immediately she got up.  This response assured us that she was in good health and hence she was discharged back to school with a prescription for better exam preparations. However, this marked the beginning of her frequent ER visits and it always coincided with the exam period.

The fourth visit prompted the need for a psychiatric consult and after assessment, she was taken in for psychotherapy and commenced treatment. According to her records, she is yet to turn up at the ER again and her final diagnosis was documented as Conversion disorder. 

So what is /hysteria? 

Hysteria broadly refers to a patient responding disproportionately emotionally to the situation at hand. It was scraped from the DSM  and in its place terms like dissociative and somatic disorders were introduced. Dissociative and somatoform disorders have been linked to patients who have experienced or witnessed trauma in some way eg physical, emotional, or sexual abuse (Verywellmind, 2022,Williams et al., 2020)

1. Dissociative disorders are further divided into;

• Dissociative amnesia, which involves forgetting personal information or not being able to recall certain events
• Dissociative fugue, which involves forgetting personal information combined with changing physical locations, sometimes creating a new identity in the process
• Dissociative identity disorder, which involves having two or more distinct personalities, each with no memory of what the other has done

2. Somatic symptom disorders -  involves having a significant focus on physical symptoms such as weakness, pain, or shortness of breath. This preoccupation with symptoms results in significant distress and difficulties with normal functioning. This includes:

• Conversion disorder (functional neurological symptom disorder)
• Factitious disorder (Munchausen syndrome imposed on one's self)
• Illness anxiety disorder (formerly hypochondriasis)

How do such patients present? They may present with one or a combination of the following symptoms (Verywellmind, 2022)

• Blindness
• Emotional outbursts
• Hallucinations
• Histrionic behaviour 
• Increased suggestibility
• Loss of sensation
• Being in a sort of trance
• Developing amnesia
• Experiencing paralysis
• Fainting or passing out (syncope)
• Having epileptic-like seizures
• Increased pain sensations
• Rigid or spasming muscles

Handling such patients requires patience and an acute sense of awareness of the possibility that there's more than what meets the eye (Levenson., 2023). Their symptoms may be very different from what is stated above. Presently there is an advent of many traumatic events. There are ranging from gender-based violence, civil unrest in different regions, deaths from emerging and emerging diseases, natural disasters etc It is our role to recognize and refer where we can. Often we act as a gateway to the quality of life our patients will get and hence we should choose the best. For most people, it is not a choice for them to present as the above patients. So be kind and keep your biases aside. It doesn't hurt to have several differential diagnoses, remember "there is a crack in everything, that’s how the light gets in."  Leonard Cohen.

References

Best Documentary. (1946). Let there be light. https://youtu.be/lW4E-MxFI_w

Levenson., J. L. (2023). Somatic symptom disorder: Assessment and diagnosis. https://www.uptodate.com/contents/somatic-symptom-disorder-assessment-and-diagnosis

Verywellmind. (2022). What Is Hysteria? https://www.verywellmind.com/what-is-hysteria-2795232#toc-what-is-hysteria

Williams, S. E., Zahka, N. E., & Kullgren, K. A. (2020). Somatic symptom and related disorders. Clinical Handbook of Psychological Consultation in Pediatric Medical Settings, 169-181. 

PRESENTLY

“One of the most important things you can do on this earth is to let people know they are not alone.”

 Shannon L. Alder

 

Allow me to reintroduce myself, my pseudonym is Lilylovelong and I am on management for a severe anxiety disorder specifically Agoraphobia. I know right...You are shocked so was  I in the beginning. Most people choose to hide but I am not like most people and here is a snippet of my experiences.  I have a great support system and so far I manage it well. Some days have been rougher than others but it is well. Presently, it is been managed with medications, psychotherapy and counselling.

                                                                                      So what are phobias?

According to DSM V, a specific phobia is an intense and irrational fear of a specified object or situation. This overwhelming fear leads to avoidance behaviour or extreme distress. Globally, about 19 million people live with some form of phobia. Is this a significant or a non-significant figure? You be the judge.

How are phobias categorised?

The American Psychiatric Association lists phobias into three broad categories:

1.  Social phobias/social anxiety disorder - is marked by a fear of social situations in which a person might be judged or embarrassed.
2. Agoraphobia - involves an irrational and extreme fear of being in places where escape is difficult. It may involve a fear of crowded places or even of leaving one's home.
3. Specific phobias - it's the phobia of a specific object such as balloons, needles etc

What risk factors predispose one to develop phobias?

The Mayo Clinic (2022), lists the following risk factors

• Gender - Women have a greater risk as compared to men.
• Age - Specific phobias occur by age 10, however, they may develop later on in life.
• Family history - It may be an inherited tendency or learned behaviour eg when a child repeatedly observes a phobic reaction to an object or situation.
• Temperament -  Studies show that risk is higher in people who are more sensitive, more inhibited or more negative than the norm.
• Negative experiences - Experiencing a difficult, stressful, or traumatic event may trigger an onset of a phobia.
• Learning about negative experiences - Hearing about negative information or experiences

Causes 

There is no known specific cause. However, different research studies describe it as an interplay of the above-listed risk factors.

So what is Agoraphobia?

McCabe E. R. (2022), defines Agoraphobia as an irrational and extreme fear of being in places where escape is difficult. In my case, I do not handle crowded places well and when I do venture I always look and seat close to the nearest exit etc.

It can occur independently or alongside a panic disorder. Often occurs in females and is often affiliated with a mood disorder

 

How does it feel like?

I felt trapped in my own body, and my thoughts were erratic due to heightened senses. I had insomnia for several days on end, The thought of opening the door to step out induced panic attacks, I cancelled hanging out with friends and family, and I had to wear earplugs at all times or earbuds and play specific genres of music to keep me calm, I was increasingly agitated in noisy environments at some point I could no longer use public transport and had to use cabs to move around etc. Generally, It was a lot and that's when I decided to take myself in for a mental assessment.

 

What helps me cope?

1. My belief in God has given me peace that I can't describe.
2. Great support networks from family, colleagues, supervisors and my friends- They keep my mind focused on what matters.
3. My doctors for being great listeners, being accessible, personalizing care and for their patience.
4. Understanding that it's a season and the storm will be managed or completely alleviated. There is great progress thus far.
5. Having access to a lot of study materials has kept my mind calm on rough days as it's a great distraction.

 So what type of care did I need in my season?

Now that the shoe is on the other foot I have quickly realized that most of the care we offer is from a sympathetic viewpoint instead of empathy and that needs to change. In my crisis priority needs were

• Readily accessible practitioners- I needed constant reassurance and guidance on the different medications I was on.
• Living with a caregiver - Some medications gave me antegrade amnesia, blurry vision syncope episodes, and dizziness. this made me a hazard to myself. 
• Time off work- My body needed time to recover, rest and adjust to the treatment and this was facilitated.
• Financial planning strategies - Agoraphobia is an expensive disorder;  during crisis episodes, one only moves around in private means, I needed to be in the company of a familiar person, I needed mouthguards, noise cancelling devices,I needed to keep my possessions in storage etc.

As a carer how do you support someone with a mental illness? 

NB: The following advice is not recommended for all patient groups 

(Better Health Channel) 2022 summarises the care into

• Talking openly and encouraging patients to be honest with their friends and family about how they are doing
• Reading about mental illnesses from reputable websites, such as government or health organisation websites or books by specialists
• Encouraging patients to take an active role in their mental health recovery, get out and see people and enjoy a healthy lifestyle
• Setting limits and letting them know what you can do for them and what you are not able to provide
• Finding out about any local or online training courses for mental health carers
• Joining a mental health support group to meet other people in a similar situation
• Take any talk of suicide or self-harm seriously and speak to a mental healthcare professional about it as soon as possible
• Putting plans in place as a backup in case you go on holiday, have to leave town or are not able to care for them for any reason 

In conclusion remember, "Vulnerability sounds like truth and feels like courage. Truth and courage aren’t always comfortable, but they're never weakness." Brené Brown

References

Better Health Channel. (2022). Caring for someone with mental illness.             https://www.betterhealth.vic.gov.au/health/servicesandsupport/caring-for-someone-with-mental-illness

Mayo Clinic. (2022). Specific Phobias. https://www.mayoclinic.org/diseases-conditions/specific-     phobias/symptoms-causes/syc-20355156

McCabe E. R. (2022). Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations,   course, and diagnosis. https://www.uptodate.com/contents/agoraphobia-in-adults

THE UNPOPULAR OPINION

"Some people see the cup as half empty. Some people see the cup as half full. I see the cup as too large."George Carlin.

As more and more people get diagnosed with some type of non-communicable disease (NCD), the more one realizes just how insidious these diseases can crop up. At this point in my life, I am of the opinion that each of us has a disease or a group of diseases that are personal to us. One may be living with it/them or slowly or rapidly you have witnessed NCDs impact people close to you. The WHO estimates that NCDs account for 41 million deaths each year and that yearly, 17 million people die from NCDs before turning 70 (World Health Organization, 2022). In comparison with different geographical regions, low and middle-income countries are more affected (World Health Organization, 2022). 

Extensive research studies have concluded that early disease detection,  health screening and treatment plans that encompass palliative care are essential for NCD management (World Health Organization, 2022). Among my list of personal experiences with  NCDs, my greatest one is stroke. Stroke forms my earliest memories of how vastly a disease can impact someone's life. In my formative years, I could quickly identify something that was different about my grandfather. I remember visiting my grandparents and wondering why my granddad had a different gait? My earliest concerns were; why was he using a walking cane? Why did he need that extra hand to perform his daily activities? Well, it turns out that before my birth he had suffered from a stroke and it had left him with hemiparesis (partial weakness of one side). Looking back, I am grateful that he was well cared for and this was evidenced by adjustments made even around his home to make life better for him. Several years later I learnt that the stroke was a result of Hypertension and that shook me. In my still-developing mind, I concluded that HTN and Stroke were synonymous. I am happy to report that I am better informed now but this experience made me realize of how valuable it is to ensure patients and patients' families need to be educated appropriately and guided on how to provide economic, social, psychological and any other form of support needed. To you my reader which disease prompted you to seek more information 

In 2022 we have vast access to knowledge on these diseases. However, it is still a worrying trend to see it loosely translated to most patient groups and families. This has a direct impact as we see it result in frequent unnecessary hospitalizations. 

I believe we can do better by emphasising improving care delivery in the most basic of ways such as

1. Formulate standard procedures and protocols and actually apply them.

It is sad to realize that GOK generates a lot of materials that end up in the archives. few institutions apply them yet a lot of funding had been directed towards their development. For example, (Division of Non-Communicable Diseases Ministry of Health, 2018). For more advanced institutions there are several resources available and of course, the oldest model of all clinical experience that's backed by feasible outcomes is applicable in those resource-limited areas.

 2. Family and patient education

It is prudent to have an honest discussion on the impact of the disease. Practice empathy instead of sympathy otherwise, you may end up having discussions and communicating nothing. Do not approach it alone utilize a multidisciplinary approach. Reinforce the information repeatedly. You also did not understand all concepts on the first encounter so stop expecting too much from them. Any diseases that need long-term treatment or lifestyle modifications are already a source of stress and may hinder comprehension in some people (Traeger et al., 2019).

Key points often missed out include:

• Impact of the medication on their daily activities/ need to modify nutrition due to food & drug interactions, duration of medication use, when to go back for review even if on medication
• Rehabilitation-  Details on how it impacts their health, breakdown of the details on the type of adjustments that may be needed around their homes eg including handlebars, cost of said therapies and how they can access them at an affordable cost but not compromising on quality
• Impact of the disease on their current roles- Roles could be within the family, income generation, societal etc

3. Make appropriate information accessible and available

Stop limiting patients by not recommending reputable sites or resources to them. For those conversant with the world wide web guide them on the selection of online forums, apps etc (Correia et al., 2022). Employing educators is needed, being an educator is among our core roles however it's not viable for staff to deliver when overwhelmed beyond their capacity. 

4. Build or encourage patients to develop support groups

There have been several studies around the role of support groups 1)improved patient outcomes and 2) increased caregiver support. These studies show that patients and families benefit more from recommended therapies if they can identify themselves in others (Enriquez & Conn, 2016). They may be virtual or involve patients' or caregivers' physical attendance. Within them, I would encourage the involvement of a clinical psychologist he/she can cater to their mental wellness when the need arises.

To sum up, there is greater urgency to a well-thought-out multidimensional approach within our different setups. Duplicating without modifying certain elements of patient care is clearly not providing the results needed. If the current situation is unchanged we will still be witnessing an exponential increase in NCDs. Honestly, aside from our clinical roles; factors like environmental influences on disease are still beyond us and what we can do at this time is improve on what is within our control. Hopefully, in this way, we can make the transition through the wellness continuum bearable. 

References

Correia, J. C., Waqas, A., Aujoulat, I., Davies, M. J., Assal, J. P., Golay, A., & Pataky, Z. (2022).     Evolution of Therapeutic Patient Education: A Systematic Scoping Review and Scientometric Analysis.   International journal of environmental research and public health, 19(10).     https://doi.org/https://doi.org/10.3390%2Fijerph19106128 

Division of Non-Communicable Diseases Ministry of Health. (2018). Kenya National Guidelines for     Cardiovascular Disease Management. https://www.health.go.ke/wp-    content/uploads/2018/06/Cardiovascular-guidelines-2018_A4_Final.pdf

Enriquez, M., & Conn, V. S. (2016, Jan). Peers as Facilitators of Medication Adherence Interventions: A   Review. J Prim Care Community Health, 7(1), 44-55. https://doi.org/10.1177/2150131915601794     Givler, D. N., & Givler, A. (2022). Health Screening.

Traeger, A. C., Lee, H., Hübscher, M., Skinner, I. W., Moseley, G. L., Nicholas, M. K., Henschke, N.,     Refshauge, K. M., Blyth, F. M., Main, C. J., Hush, J. M., Lo, S., & McAuley, J. H. (2019). Effect of     Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low     Back Pain: A Randomized Clinical Trial. JAMA neurology, 76(2), 161-169.     https://doi.org/10.1001/jamaneurol.2018.3376 

World Health Organization. (2011). NCD Global Monitoring Framework.     https://www.who.int/publications/i/item/ncd-surveillance-global-monitoring-framework

World Health Organization. (2022). Noncommunicable diseases. https://www.who.int/news-room/fact-    sheets/detail/noncommunicable-diseases

FINAL LAP

 "Live like a candle which burns itself but gives light to others." Anonymous

This previous month of September has been quite surreal for me. Fortunately, it wasn't a waste as I also learnt a few things. Albeit looking back I can identify a few lessons I would have loved to skip. 

 One specific occurrence that has shaped me has been the death of a former senior colleague. To many she was a friend, a confidant to her family she was a mother, to her spouse, she was a wife and to me, she was a mentor. She was the personification of charisma.  It wasn't because of the words she said but because even in being silent around her I would still learn. Looking back I am grateful that I met her and even more glad to have learnt many things while being in her presence. It is sad that I write this posthumously but it is also so beautiful that I can recall many great lessons and today I chose to share two among the many.

1. She taught me transformational leadership

 As John C Maxwell says, leaders are meant to help others become the people God created them to be and this was her everyday life. A few years back, I had an epiphany about what I wanted to evolve into. Armed with this idea  I approached her, for about thirty minutes she listened as I rambled on quite incoherently, to be honest. I can admit this now but at the end of it, she had accepted my request to shadow her staff in the intensive care department. I needed to learn a few of the basic skills before considering placing my request to switch areas of clinical practice. She quickly highlighted my strengths as exhibited in our previous interactions and linked me to personnel within the team that she considered would be a great asset to me. That conversation and subsequent interactions reinforced my confidence in the acquisition of new skill sets. Well, several months later despite my request being somewhat dismissed and I failing the interview things finally worked out and because of her I followed through on what I had set out on learning.

2. She epitomized being graceful

About 5 years ago, I was writing a paper on Chemotherapeutics and that led me to visit the Chemotherapy unit in which she was actively involved. Observing her made me understand the concept of being graceful because Chemotherapy units are one of those places that need people who have a certain Je ne sai quois about them. On my first visit, the department was quite busy so I just waved her a quick hello and took a seat waiting to get an opportunity to have a brief meeting. From where I was seated I saw patients light up when she attended to them as if on cue to a silent instrumental she met each patient where they were both physically and emotionally. Her zen energy was almost palpable and at that moment I understood why her patients were so much at ease. When a patient was in low moods she pulled a seat and just engaged in a calm conversation with them and by the time they were done you could see the patient's eyes light up. It appeared like with each conversation she rekindled something new within them.

During her hospitalization,  I could not muster the courage to see her, it was traumatic for me to envision her in so much discomfort and despite working in an area where this occurred often she was my kryptonite.  Anyway, through the support of a colleague, I finally managed to spend some time with her. I am glad I did because in that brief encounter I was just in awe of how amidst the ongoing events she tried taking things in stride. Key word being tried, she tried doing her best even when her body was failing. She never even despite the varied emotions coursing through her, let it out on anyone and to me, that spoke volumes. 

In summary, for anyone who is waiting for a time to come, for them to start living their best life may you always remember that "Life is short, fragile and does not wait for anyone. There will never be a perfect time to pursue your dreams and goals other than right now" ~ Rachael Bermingham

COMING FULL CYCLE

“Power always brings with it responsibility.” Theodor Roosevelt

In the recent general elections, so many health workers participated and got elected to different posts mostly the member of parliament and member of county assembly posts. This is a great stride because if they play their cards rights we might finally be heard. However, I do not wish to be the grinch, but I must ask. Do you think we will benefit? Personally, I do not know but time is our ally, and it shall reveal the truth to us.

 

If we were to base it on different experiences in our current or previous workstations we would further appreciate the validity in saying I do not know. For instance, are you a leader/manager in your current role? If not are you happy with the kind of leaders/managers that oversee your practice? What is the reason behind your response? You get the gist, don’t you? If this is the first time you are authentically pondering on it, take your time. If you are a leader ask yourself if the roles were reversed would you be happy receiving the same treatment you provide? If you are not a leader/manager when given the opportunity, will you mimic what you see? 

If you are unsure there are diverse ways to have a bare minimum understanding of your interactions with people. I will just list three and you can look up more later.

1. Ask for an honest opinion from someone you oversee - As you do so please be aware your feelings  may get hurt but it should not give you an opportunity to be vindictive and personalized. Be open to hearing their opinions first and self-reflect. In that conversation, emotional intelligence is key.

2. Use available leadership, management, and accountability assessment tools- Where our system fails is assuming that just because someone is great in the clinical area it automatically translates to them being a good leader or just because someone has taken up leadership courses they translate to great managers. This is a false belief and if we were bold enough to admit it we would realize that it does not always pan out as expected. Being an effective leader and manager is a delicate balance. It calls for building competence in these two fields and dancing to the rhythm of accountability. It calls for continued learning and never getting too comfortable such that one is no longer productive but more entitled and dismissive. It calls for use of regular self-assessment tools to identify one’s gaps. Plainly put such tools are a way to take a personal inventory and identify one’s strengths and weaknesses. Examples of such assessment tools will be highlighted below.

3. Have mentors - Please get someone who is challenging you to be better. Iron sharpens iron. A good mentor corrects you lovingly but firmly, coaches you on the right but often uncomfortable path, and encourages you. Being your best is not for the faint-hearted.

The traits of a good leader can be innate and acquired. However, both require taking time to refine them. Please, do not be hard on yourself if you are yet to get there just keep trying. Some of these skills include:

1. Being an effective communicator- Proper utilization of verbal and nonverbal cues is essential. It is not the number of words/actions spoken its about the quality.

2. Be empathetic - Often when people are elevated to positions of “power” I use this word lightly, of course, we tend to forget our backgrounds and become disengaged. Empathy is a skill possessed by a few, but it creates such a difference.

3. Be an efficient delegator - Do not try to do everything to prove a point but also do not delegate the things you least enjoy doing just because you can. This is an acquired trait so learn about it.

4. Establish trust – Trust builds safety as it allows people to communicate their vulnerabilities, it also may reduce turnover, improves morale, and often also reduces workplace anxiety. Ever wish to open on something and someone quickly responds by saying be careful these walls have ears. BE cautious this is coded language and translates to there being no trust within the organization.

5. Be a lifelong learner- Leadership and management is a great opportunity to acquire new skills. Building a knowledge base in your field is essential to keep people inspired to be better. It has no formula so utilize what works best for you.

6. Empower others- Building the skills you can identify among your team members not only builds respect but is also a great avenue to ensure the team is efficient. Otherwise, if you must always be in the limelight... I need not say more.

6. All the rest- Be great at Organization, Coordination, Collaboration etc

In conclusion, as you seek to evolve into being better at your role or in a new role do not forget that "a good objective of leadership is to help those who are doing poorly to do well and to help those who are doing well to do even better." Jim Rohn

References

1. https://hbr.org/2019/11/the-leader-as-coach

2. https://oxford-management.com/

3. https://oxfordsummercourses.com/articles/effective-leadership-skills/

4. https://www.leadershipsuccess.co/critical-leadership-skills/common-leadership-assessment-tools

WEIGHT, A DICEY AFFAIR

NB: This is work I had published previously on a different platform in 2021.

“Self-care is never a selfish act - it is simply good stewardship of the only gift I have, the gift I was put on earth to offer others. Anytime we can listen to true self and give the care it requires, we do it not only for ourselves but for the many others whose lives we touch.” Parker Palmer

 

Can you perform two minutes of effective CPR without feeling like you may need to be resuscitated too? Most of us dread it. We are so unfit that often it is the main indicator of our fitness level. We spend many hours taking care of others that we forget to care for ourselves. Two minutes of CPR have us breathless and on the verge of collapsing. If you don't believe me just steal a glance at your colleagues after they complete one cycle of CPR during a mega code.

Better still glance at your colleagues as you read this how many of them look fit? To correctly determine one's level of fitness we need to use quantitative measures and merely not visual inspection. After all, are we not the propagators of evidence-based practice? At this time, however,  just humour me and think about your colleagues. How many colleagues are complaining of fatigue yet it is just the start of the shift? How many are undergoing treatment for lifestyle-related conditions? Are you one of them? 

In a study done by Kyle et al. (2017) a quarter of nurses in England hospitals were considered obese. Comparatively, this was a lower figure than for nurses in Australia (28.5%), New Zealand (28.2%),15 the USA (27.0%), South Africa (51.6%) and Scotland (29.4%). What about Kenya? I think it is time we explore the figures.  

Often, the general population expects health workers to have lesser rates of obesity due to enhanced health awareness. However, from different studies such as the aforementioned one we realize that there isn't much statistical weight difference between the two cohorts.

The World Health Organization (2021) article on obesity states that most of the world's population lives in countries where overweight and obesity kill more people than being underweight. The article further details how the deaths related to being overweight and obese are a result of cardiovascular conditions, malignancies, and musculoskeletal disorders. This is quite concerning. So, what makes us be at risk?

Most studies link it to our uptake of longer shifts, notably nightshifts. However, it is not a clear-cut cause and effect due to the association of other confounding factors. Nonetheless, it would be a great area for further exploration. Below are links to some studies on this topic.

Shift work and abdominal obesity

Prevalence of overweight and obesity among nurses in Scotland

Obesity among the general population in South Africa

Prevalence of overweight and obesity among healthcare workers in Nigeria

 Some proposed reasons for the increased prevalence of overweight and obesity among health workers include.

1. Adopting poor dietary habits is linked to frequent snacking and disproportionate caloric intake.
2. Low recreational physical activity.
3. Sleep deprivation- This leads to a decrease in leptin levels which is crucial in appetite suppression. When this occurs it leads to elevated ghrelin levels which enhances appetite causing weight gain. Often this is due to the need for increased caloric intake without adequate caloric expenditure.
4. Night shifts lead to disruption of the circadian rhythm yet it is needed in controlling the sleep-wake cycle and this results in unplanned weight gain.

Due to the nature of our work, we cannot do without shift work but we can try to make some modifications to try to curb this problem. Some recommended solutions by Kelly and Wills (2018) include.

1. Organizational level changes

• Provision of staff meals. There should be an option for healthier food/snack.
• Release staff for exercise sessions within the working days.
• Generate in-house programs that encourage physical activity.
• Conduct yearly staff wellness checks that include nutritional assessments and services.

    2. Personal behaviour changes

• Seek to practise more self-care.
• Be intentional about adopting healthier food options.
• Due to the possibility of decreased physical activity, try increasing the number of steps taken each day.  For instance, take the stairs more instead of the workplace lifts. 

In summary, as we try changing the health patterns among our patients, we should remember that we can only create a permanent positive impact in their lives when we adopt the same because  "The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires." William Arthur Ward

                                                     References

Kelly, M., & Wills, J. (2018). Systematic review: What works to address obesity in nurses? Occupational Medicine, 68(4), 228-238. https://doi.org/10.1093/occmed/kqy038 

Kyle, R. G., Wills, J., Mahoney, C., Hoyle, L., Kelly, M., & Atherton, I. M. (2017). Obesity prevalence among healthcare professionals in England: a cross-sectional study using the Health Survey for England. BMJ Open, 7(12), e018498. https://doi.org/10.1136/bmjopen-2017-018498 

World Health Organization. (2021). Obesity and overweight.

A MOMENTS INSIGHT

"No one can whistle a symphony. It takes a whole orchestra to play it."  H.E. Luccock

Globally, there has been increasing emphasis on effective teamwork in healthcare.  von Knorring et al. (2020) documented how quality teamwork has been linked to improved patient safety. Some of the examples include;

1. Reducing patient complications - Effective communication is a component of teamwork and it allows for discussions on personal, system or equipment errors identified. This, therefore, aids to mitigate or prevent adverse events by formulating solutions. 
2. Decreasing the length of hospital stay- Rendering optimal services by competent teams allows for early diagnosis hence early treatment or initiation of early rehabilitative measures.
3. Improving patient and employee satisfaction - Great relationships in our workstations foster productive environments improving the quality of services rendered to patients.
4. Decreasing costs of care  - prolonged hospital stays lead to increasing financial burdens to patients and their families.

So what is teamwork? 

"Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results."  Andrew Carnegie

Are you part of an effective team? 

Bisbey and Salas (2019), state that effective teams are characterized by the following six Cs. These are  

• Cooperation - Diverse groups of people willing to work together for a common goal.
• Communication - Passing clear and correct information to other people and comprehending what is being said to us.
• Coordination - Ensuring synchrony of different roles.
• Conflict management -  Diverse mindsets create friction hence the need for early identification of problems and seeking solutions before an issue escalates.
• Coaching - A process of equipping employees with the knowledge, tools, and opportunities necessary for them to be effective.
• Shared cognition among team members- Involves having a competent team that understands the task at hand.

Teamwork is affected by many things some within our locus of control and others beyond. This understanding is cardinal in formulating an effective team. The literature describes several internal and external factors that influence teams. Some of these are; 

• Organizational characteristics- does it have a clear purpose, clear job roles among the members, appropriate culture eg support culture of safety, specified task, appropriate choice of leadership, hiring competent personnel, adequate resources
• Individual contributions - Professional self-image,  ability to confer/receive trust, commitment to the task, flexibility to different opinions.

Among the different types of health workers, the bulk is formed by both nurses and doctors, therefore, a lot of literature exists on their interesting team dynamics. Just perform a random search on HINARI, PUBMED etc there is a lot. So how then do we identify if we are part of an effective team? The answer lies in us evaluating our performance measures (Agency of Health Care Research and Quality, 2015)

According to the Agency of Health Care Research and Quality, 2015 & Schmutz et al., 2019 these include; 

• Process-related outcomes( adequate behaviours during processes) - eg Adhering to formulated guidelines, attitudes expressed at work, 
• Outcome related aspects of performance - eg Infection rates postoperatively, patient survival rates etc

In summary; as we look at improving our  output (job satisfaction, patient outcomes let's remember "Individual commitment to a group effort that is what makes a team work, a company work, a society work, a civilization work." Vince Lombardi

References

Agency of Health Care Research and Quality. (2015). Types of Health Care Quality Measures. https://www.ahrq.gov/talkingquality/measures/types.html

 Bisbey, T., & Salas, E. (2019). Team dynamics and processes in the workplace. In Oxford research encyclopedia of psychology.

Schmutz, J. B., Meier, L. L., & Manser, T. (2019). How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. BMJ Open, 9(9), e028280.

von Knorring, M., Griffiths, P., Ball, J., Runesdotter, S., & Lindqvist, R. (2020). Patient experience of communication consistency amongst staff is related to nurse-physician teamwork in hospitals. Nursing Open, 7(2), 613-617.