Eastwood Clinic & Change!

Hi everyone! I hope you’re ready to hear about my new clinical rotation in Eastwood Clinic, because I finally have time to write about it!

On Tuesday, 10/28, I had my first day at the new clinic. From the moment I walked in, I could tell that it was a lot different than East Boom. My first thought was, “Wow this clinic is tiny!” In reality, I had just been at one of the biggest clinics in town, so this was a normal sized clinic. Inside, there was one waiting room packed full of people, four exam rooms, an immunization room, and a front desk. I was assigned to work with the only nurse on duty, Sister Dlameni. She was totally stressed when I walked in because all of the other sisters were out “sick.” I found out later that they were constantly understaffed at the clinic and were lucky to have two sisters working at the same time. I offered to help in any way I could since the sister was obviously overloaded. She agreed and let me take over the 6 week assessments, which I didn’t mind at all because I love babies and had already learned how to do them at East Boom. The cool thing about this nurse is that she sees everyone from babies to children to PMTCT moms to TB patients (which there were a TON of) to men with minor ailments; thus, she is incredibly experienced and knowledgeable in all populations and corresponding health issues. I never got a chance to go to the TB clinic at East Boom (ok, honestly, I didn’t really want to because I didn’t want to come back to the US with TB), so it was really interesting for me to interact with the multiple TB patients and learn the treatment and documenting protocols. Sister Dlameni has a huge book called the “South African Department of Health National TB Control Program – TB Registrar” where she is required by law to write down the patients with TB and everything pertinent to their diagnosis, like the type of TB (primary, disseminated, abdominal, etc.), sputum smear results, HIV status (which is usually positive because TB is one of the most common opportunistic infections in an HIV infected person), treatment start date, and traceable address. On another form, the sister writes down all of the patient’s TB contacts and informs the patient that all of the contacts need to do a sputum or Manteaux test. Unfortunately, a majority of these contacts fail to return, which is one of the reasons TB continues to spread like a wildfire in South Africa. The only part I didn’t enjoy about the nurse was the fact that she continuously complained about being stressed and overworked. I completely understood why she felt the way she did; however, her complaining about something that could not be changed did not allow for a very positive working environment for her, the patients, or I.

Later in the week, on Friday 10/31, I was assigned to work with Shaun, the immunization nurse. He actually only has a 2 year degree, so he is called a staff nurse rather than a sister (who has a 4 year degree). Shaun was really fun to talk to and very willing to teach me about the various injections. He also had no problem letting me take over his job, which is something that I don’t always get to experience as a student nurse. I became very familiar with the child immunization schedule, which is very different from that in the U.S. The most common injections we gave were DTP-Hib, Hepatitis B, Petogen-Fresenius (a progesterone contraceptive that’s given every 3 months; Shaun and the patients just call it the “Family Planning” shot), penicillin, and ceftriaxome (for direct observed therapy, or DOT, of TB management). Unfortunately, we ran out of Hepatitis B pretty early on in the morning, so we could only immunize most of the babies with DTP-Hib. Apparently Shaun had ordered it a few days prior, but it hadn’t arrived yet. I couldn’t believe that they just ran out of immunizations like that. Honestly, it made me kind of frustrated. The children are the ones who suffer; just because the government doesn’t make it a priority to get the vaccines to the clinics in a timely manner, kids become at an increased risk for contracting diseases. Another issue I noticed had to do with the tube holders used in blood draws. At East Boom, the tube holders have a built in safety mechanism that allow the nurse to simply click off the needle into the sharps container. This prevents any accidental needle sticks. Oh, I forgot to mention that nurses in SA reuse the disposable tube holders because 1) they never actually come in contact with the patient’s blood and 2) they don’t have enough money in the budget to buy more than a few at a time. Anyway, the tube holders at Eastwood do not have this safety mechanism. Shaun literally has to screw the needles off after taking bloods. He informed me that he has had 3 needle sticks (and could potentially be infected with HIV because of them) in the past 4 years because of this lack of safety feature. Although I drew bloods at East Boom, I wasn’t about put myself at risk, so I let him do those for the day.

On Tuesday, 11/4, I got assigned to work with Shaun again; however, there were already 3 South African nursing students shadowing him. One of them was a third year student from Grey’s Hospital studying to become a sister, while the other 2 were second year students from a private nursing school training to become staff nurses (like Shaun). They had pretty much taken over the immunization process, so I was left to stand in the corner of this very small room. Shaun was in and out of the room the entire morning because, once again, there was only one sister for the entire clinic and she needed his help. When he left, he told me to “take care of [the student nurses]” and “make sure they don’t mess up”; hence, I became their instructor. It was kind of cool for me to teach these girls because for the past 3 years, I have been the student needing instruction. I’ve finally moved my way up the nursing ladder! These student reminded me exactly of how I used to be when I first learned how to do injections my sophomore year in Med-Surg. Their hands were shaking and they were fumbling around with just about every piece of equipment they came in contact with. One of them even managed to stick herself with a needle. Fortunately, it was before she had administered the immunization, so it was a clean needle. It was so strange for me to see their complete lack of universal precautions. They didn’t wear gloves, walked all around the room with uncapped needles, and touched all of the parts of the needle that shouldn’t be touched. I attempted to bestow some of my knowledge regarding injections and precautions without seeming condescending, and they seemed pretty receptive to my teaching. When the students went on tea break, I got to take over the immunizations while Shaun charted. That was the only time I got a break from the supervisor/instructor role; otherwise, I continued helping the students for the rest of the day.

So those were my most memorable days at Eastwood thus far. Now I have to tell you about something my fellow nursing students and I have been working on this past week in regards to this clinic. For our Community Health class, we have to assess, plan, and implement a nursing action for the clinic we’re working in. After seeing the major risk for needle sticks Shaun was being put at, we (Corey, Mandy, and I) decided that getting him safety tube holders would be our project. At first, we were just going to go out and buy him a few and be done with it; however, as we discussed it more, we realized that we couldn’t just do the “rich American thing” and simply buy our way out of a problem. We had to actually make an effort to change the policy of the clinic; additionally, we wanted to get that policy implemented in the 21 other clinics in the area that are all under the same management. With the help of one of our South African nursing professors, Glenda, we were able to get an appointment with the nurse in charge of infection control and the Expanded Program in Immunizations (EPI) over the entire municipality (22 clinics, including Eastwood).

On Wednesday, 11/12, Mandy, Corey, Glenda, and I drove to the municipality to meet with this woman (Sister Goga). She was really sweet (but straightforward at the same time) and turned out to be the perfect person to talk with about implementing these safety tube holders in the clinics. In her position, she gets notified of reportable diseases, investigates in the community and does reports, performs an outbreak response in which she immunizes the community where the outbreak occurred, visits clinics to ensure certain standards are maintained within immunizations (that’s where we come in!), and also trains staff about new immunizations. She was the first nurse to start infection control awareness in the community 5 years ago; there was no one in her position before. Obviously, she plays a huge role in community health and I can’t imagine what the system was like before she started her job. Anyway, we presented to her our idea regarding the safety tube holders, and she seemed very receptive to it. To implement any change within the clinics, all she has to do is send a letter of requisition/motivation to higher power. This letter basically does exactly what it sounds like: it requests of and motivates people in charge of supplying and budgeting to do something about the problem. So to implement our proposed change, she would have to write this letter. Instead of trying to figure out how to write the letter then, Sister Goga invited us to present our idea to her monthly Infection Control Committee meeting, which happened to be the next day at 2:30PM. We were so excited when we heard this and readily agreed.

So the next day (Thursday, 11/13), we did class presentations for Nursing Research all morning and then headed off to our very important meeting. There only ended up being two people there because all of the other nurses had last minute meetings to attend; however, the people that were there were the most important ones. One was Sister Goga, obviously, and the other was Sister Solomon. She is the senior district nurse (SDN) for Eastwood and Mason’s (which is the other clinic we have students at), so she was the perfect person to be in the meeting. Although they had to reschedule the meeting for the following week, they’d already planned for an hour and a half out of their day, so they invited us to present who we were and the change we wanted to implement. As professionally as possible, Corey, Mandy, and I presented our idea. They were very receptive to the idea and told us that they had actually tried to implement something like this before, but there were budget constraints and it didn’t go through. Both of the sisters expressed a desire to change a lot of unsafe practices within the clinics; unfortunately, a lack of monetary resources has not allowed them to do so. This was such a sad thing for me to hear. These nurses work so hard to create safer conditions for the nurses and patients, only to be shut down by budget constraints. Glenda, who was sitting in on the meeting with us, then mentioned that APU is giving $500 to each of the 3 clinics we’re working at (out of our tuition), and maybe we could use part of that money to supply all 22 clinics within the Municipality with one or two safety tube holders. One tube holder costs $5, so it would only be $220 to suppl all of the clinics with them. This would prevent accidental needle sticks and the spread of communicable diseases like HIV/AIDS, potentially saving the lives of multiple nurses. The sisters were SO excited about Glenda’s proposition and said they would be SO happy if we could buy their clinics some tube holders. Glenda told them that as soon as they decided what company they wanted to buy them from (since the end of apartheid, the government has required that clinics only buy medical supplies from companies that are Black Business Empowerment [BBE] compliant, meaning that they have a certain number of black people in management), we could buy them and hopefully bring them to our final clinical day next week. The sisters readily agreed, and I was pumped. After that victory, the sisters proceeded to ask us if there was anything else that we noticed needed improvement within the clinics. I couldn’t believe the opportunity they were giving us, so I started talking right away. The first thing that I mentioned was regarding the innovation paper and presentation I completed for Nursing Research that very morning. For this project, we had to find a research article from a topic of interest and apply the study’s intervention to a clinical setting we’re familiar with. I chose an article regarding the analgesic effects of breastfeeding and maternal holding during painful procedures like heel-sticks and applied it to East Boom clinic. Heel-sticks are common procedures performed in the U.S. during baby’s first few days of life to test for various metabolic and endocrine problems (PKU, hypothydroidism, & galactosemia). In SA, they are commonly performed during the 6 week check-ups to test the baby for HIV; however, at East Boom, I have noticed no attempts for pain relief. Basically, the baby lies on the exam table crying until it can cry no longer while the nurse squeezes blood from its heel for 3-4 minutes. It was absolutely heartbreaking for me watch and totally unethical. Based on the findings in the study, I suggested that the sisters educate the mothers to either hold their babies or breastfeed during this painful procedure to decrease pain. They had never heard of such a simple and cost-effective intervention and seemed to take great interest in implementing it. We also told them about the lack of soap at any of the sinks in Eastwood, how only one nurse has a TB mask, how the linens aren’t changed between patients (even with pap smears), and how none of the staff use gloves. Then we suggested changes to these unsafe practices. Sister Goga and Solomon wrote everything down and seemed very interested in all of the suggestions we gave. The meeting lasted a good hour, and by the end of it, I was so excited. I can’t even explain it. These women were key players in enacting changes within the clinics and we had to privilege to meet them and give them suggestions to improve their practice. We really are making a difference in people’s lives! Not only has this been this goal of mine in SA, but in life as well. It’s one of the reasons I chose to become a nurse. I want to make a difference. I want to be the person who people look back on and say, “Wow. I don’t know where I would be without Nicole’s influence on my life.”

So that’s a summary of my amazing time at Eastwood clinic. I have one more clinical there next week, and can’t wait to update you on what has happened. Believe it or not, I only have four more weeks in South Africa. Time has absolutely flown by. Nursing is getting more stressful by the minute, and I’m currently working on my huge senior seminar ethics paper. Please keep me in your prayers as I try to balance the craziness of school with my final weeks in this amazing country. I’ll try to write again within the next two weeks!