INSIDE VOICES PLEASE PART 2

 "Memory is fragile and the space of a single life is brief, passing so quickly that we never get a chance to see the relationship between events; we cannot gauge the consequences of our acts, and we believe in the fiction of past, present, and future, but it may also be true that everything happens simultaneously."   Isabel Allende

 Have you recently handled a dying patient? Are you currently handling a dying patient? How do you feel about it? A few months ago I had to take a video of a dying patient for his family as a final request. He had flown into the country as a tourist but unfortunately, he got critically ill. He had traveled unaccompanied and tracing his family was quite arduous. His condition gravely worsened to a point where he was on treatment failure. When his family was finally traced and contacted it was almost too late. To help them cope with this situation his father requested a video. He could not bear seeing his son who has been physically fit in such a state. He was also buying time as he tried to figure out a way to disclose this information to the rest of his family back in their homeland. He was too heartbroken to physically see him and I felt for him. Imagine being in his situation. How strong are you to handle such events? These words sound familiar, right? Well, I have written them before in a blog post titled Inside voices please part 1. I did not abandon the conversation I just needed an appropriate time and this is it. 

 In healthcare like in any profession, it gets to a point where some things become mundane then there are other activities that you just cant acclimatize yourself with. You may be physically okay but for a briefly these moments remind you of your mortality or the mortality of your loved ones. I hope at least one person who reads this today learns from it or realizes that they are not alone. Do you remember the patient I mentioned at the start of today's post well he died the same day I took the video. For a while, I thought I was handling it appropriately. It was not my first death and surely not my last so nothing really stuck out except for this feeling of anticipatory grief that had started a few days before his death. After a few days, it turned out  I was not coping well. I found myself being too emotional, whilst alone I would cry at the most inappropriate things, I wished to be alone despite my friends wanting to spend time with me, most of my anger was unwarranted, I was hyperventilating on some days and I had nightmares so I couldn't sleep adequately. This may not come off clearly here for its just a snapshot of an extensive timeline so bear with me. I finally knew something was off when I realized I hadn't shown up for work. On this day I woke up, showered, got dressed, tried opening the door but I couldn't. I had an overwhelming feeling of anxiety so I decided to switch off my phone and went back to bed. About an hour later, I woke up took a public service vehicle, and went to a spot where I often go to meditate. For most of that day, I was unreachable. On that day I just did not understand what was happening. 

Later on that day I learned that some of my colleagues and friends had been looking for me and when my best friend showed up that's when I established the root of my problem. All this had resulted from the loss of my patient. It turned out that I had not addressed it adequately. She allowed me to vent, cry, curse out and she didn't leave till I felt better. This was the catharsis I had needed all along. I had a lot more to do thereafter, and I did. This situation reiterated the fact that no matter how used to death you think you are. There will be days that are tougher than others and it is okay.

  

 Globally Covid 19 infectivity is at an approximated 12million people and approximately 500,000deaths why I state approximately is because by the time I publish this post the figure will have changed. View current data here W.H.O data link. Current research is showing that Covid 19 mortality rate increases mainly with age extremities and having a history of an underlying medical condition. One such study is a predictor of mortality Please review it for a greater understanding. With a vast majority of our population having non-communicable diseases it means that more health workers will soon be experiencing the same things as I if not worse. Are we prepared?   I chose to share findings from a study done in China because it being an epicenter I believe it gives a good example of the magnitude of the problem. The researchers who conducted this study were aiming to examine the impact of working among populations greatly affected by the Covid19 pandemic. Their results show that a large proportion of the participants had symptoms of depression "(634 [50.4%]), anxiety (560[44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline workers, and those in Wuhan reported experiencing more severe symptom levels of depression, anxiety, insomnia, and distress". I highly recommend that you read it mental health outcomes

 Borrowing from personal experience we can try to cope with these feelings by;

1. Utilizing availed resources-Currently, most organizations and facilities have established mental wellness programs for health workers. If your facility has not, try and see how you can help in establishing them. It can be as simple as taking five minutes each day as a team to share a few things you are grateful for at the start of each shift.

2. Stop criticizing each other when you realize someone can't cope with what you can. We are all unique and different.

3. Consider utilizing our untapped skills. Maybe among us are great optimistic leaders who can offer some form of reassurance when we feel overwhelmed.

4. Take care of yourself more intentionally. When its time to rest guard that time preciously. We cope better with difficult scenarios when rested.

5. Open discussions with our different support systems. Let them know beforehand that the journey at times is really difficult and sometimes all you need it time, patience, and love.

6. Be open about what you are going through. 

7. To the leaders, supervisors, managers the roles may be different but do not judge nor be quick to dismiss. Be more empathetic to your staff. Ask them "how can we help rather than why did you do that? "It encourages effective communication.

Despite how today or tomorrow is, just know it does get better. We have successfully weathered out other pandemics as professionals and we shall get through this too. "Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying 'I will try again tomorrow."Mary Anne Radmacher

ZUSAMMENARBEIT

"Never look down on anybody unless you're helping them up."  Jesse Jackson

 How many hours do you spend at work? Do you find them productive? Have you ever noticed how your interprofessional collaboration impacts the productivity of your day? Studies actually show that ineffective team dynamics actually put patients at risk, it also affects the level of job satisfaction among nurses and this also impacts their retention within an organization. We may think that it is a current problem but it isn't. In a study done in 2002, It was estimated that 41% of hospital nurses were dissatisfied with their jobs, and 22% planned to leave them in less than one year (among nurses younger than 30, this figure was 33%).The strongest reasons cited for respondents’included discontentment with being overworked, staffing cutbacks, increased caseloads, increased non–patient care duties, little to no concerns about care quality, verbal abuse, and lack of administrative concern." Some of us may be quick to dismiss it as a dated article but are these not the same issues we are grappling with now. For anyone interested please view this article here nurse-physician relationship. Within Africa, very few studies have been done on this. This is quite unfortunate because day in day out, we experience different scenarios that highlight how the interplay of the role of the different professions affects the clinical outcomes for patients.

On a personal level am appreciating how this current Covid 19 is bringing so many things to light. For instance, have you noticed how many webinars currently are inter collaborative efforts? We are finally coming around to the idea that for us to attempt controlling this pandemic we need to generate synergistic relationships. It became quite clear from the start of the pandemic that one profession cannot succeed without the other. Over the years there has existed a lot of friction between the nursing field and the medical field but slowly things are changing. Hopefully, there will come a time when it will be in the distant past. So have you ever consciously looked into why our team dynamics sometimes fall below par? Well, I did, and here is what I came across.

Firstly I noticed it was an area where little volumes of data within Africa exist. That I deduced maybe as a result of the provision of patient-centered care being a new or relatively new concept in the majority of health institutions. If interested read this document and draw your own conclusions people-centered health care. Secondly, this patient-centered care due to the expenses inculcated in the implementation of the policies and services has mostly been taken up by the private health sector. Why? because within the public health sector how will these costs be transferred to the patients/clients and services still be provided at a subsidized cost. How will accountability be achieved yet every day we wake up to new corruption scandals? Anyway, before I digress much further let me get back to my core topic for the day.

Ever wondered what are some of the causes of the interprofessional disengagement? A study done in Tanzania to examine interprofessional collaboration on the clinical decision-making process and outcomes concluded that disengagement resulted from;

• The nurses' role not being clearly understood and this leads to nurses being perceived as professionals who should just receive orders and not question them, 
• Nurses being considered to lack the clinical expertise as "their level of education is lower than that of medical doctors."
• Stressful work environments that lead to  fatigue due to excess workload, inadequate time frame,
• Authoritative positions only being held by the medical doctors
• Provision of clinical suggestions that are not scientifically based.

Before everyone is up in arms those are some conclusions from this one study in which you can view here the status of nurse-doctor collaboration. We all, however, can conduct more studies and generate to this pool of resources, and maybe the conclusions may vary.

What are some of the ways you have participated in abetting or terminating the interprofessional drift? Who suffers. Let us look into it;

During my clinical rotations as a student, I had gone for my operating theatre placement. On this particular day, I had scrubbed in for a partial hip replacement surgery now most people know how frustrating it can get when the surgeon attempts to place back the head of the femur with the prosthetic ball. Sometimes it is not easy and this was one such case. He got frustrated and within no time tension built up rapidly and soon instruments were being tossed over people's heads with the claim that all the instruments were dysfunctional.No one said nothing, some of us walked out the room not to return. The patient was under spinal anesthesia and could hear everything. A  surgery that would have taken about two hours ended up taking four hours. It eventually ended successfully but let us examine the events.

1. The patient received more dosages for the anesthetics than necessary. This predisposed him to a greater risk for adverse drug reactions.

2. There was exposure to preventable psychological trauma to the patient and staff present. As a patient can you imagine being in an operating table and having your caregivers argue? You will be unsure of the quality of care being provided to you. For the caregivers, our safety was threatened. Our reaction was not the best but we soon learned from it.

3 This situation resulted in increased costs for the patient. We know that theatre charges in most organizations are calculated at a specific rate per hour. He was in for an extra two hours as the team was being gathered again to continue.

 Another example would be when a nurse doesn't wish to confirm a dosage for a drug like Gentamycin in an infant and administers the stated dose. Let us assume it was an overdose and we end up with the infant developing drug-induced kidney injury. Who suffers at the end of it? Something needs to be done. Great progress is happening to mend the drift but we need to expedite it. It is possible and we are already on the right path.

Try and think of a time when interprofessional harmony aided in the quick recovery for a patient. Or when it bailed you out of a situation that would have culminated in a court case. What about on those days when this harmony created such a peaceful work environment that it aided in your peak productivity. Wouldnt it be nice if it was the set standard everywhere? Each of us can play their role in making it a reality for example;

1.Nurses

• Encourage participation in other departments’ training- This may help nurses better empathize with the challenges their colleagues in other disciplines face.
• Promote multidisciplinary rounds- This provides avenues for asking questions, seeking clarification, and discussing patient goals with other providers.
• Keep the focus on the patient - Remind providers that the goal of the approach is to ensure patient satisfaction.
• Be bolder in explaining our evidence-based suggestions. 
• Be okay with being uncomfortable. Respect is never demanded it is earned.

For an in-depth elucidation on some of the above points please review the documents below

a) nurses perspective

b) Interdisciplinary ward rounds

c) Integrated literature review

d)Conceptual framework

Role of the health facility administrators and teaching facilities

• Generate staff training programs for interprofessional education- This enhances communication by encouraging discussion of shared cases and provision of immediate feedback.
• Interprofessional curriculum development and delivery - eg At Tribhuvan University’s Maharajgunj Nursing Campus in Nepal, the curriculum on newborn care was updated at a workshop that included nursing and medical faculty. Participants worked together to identify the essential components of a new curriculum. They found that the nursing faculty were more knowledgeable and skilled in areas like essential newborn care while the medical faculty were more knowledgeable and skilled in advanced care.

 For more examples of how organizations can effect this please view the following document   Framework for action on interprofessional education & collaborative practice. 2010.

For greater strides to be achieved in the delivery of our different services we should not leave any profession lagging behind. There is always strength in numbers remember, "teamwork begins by building trust. And the only way to do that is to overcome our need for invulnerability."  Patrick Lencioni