New Nursing Curriculum – Update

Before she heads back to the UK at the end of her 15 month placement, our Nurse Educator Linda provides an overview of the curriculum implementation planning.

 

Nursing education leads at COMAHS are making good progress with designing their new curriculum for registered nurses. They have been working with me for the last year and the journey has been long and winding but is really taking shape now.

On Friday 20th November, I assisted the Faculty of Nursing team to work on an implementation plan for the new programmes which will start in 2018. It is quite a challenge to develop the detail of a plan such as this. The faculty staff welcomed the opportunity to get started, building on their expertise in delivering the current nurse education programmes. One example of a change in the new curriculum plans came from the feeling that degree students had plenty of theory base but less clinical experience. The new curriculum is focused on introducing clinical practice for degree nurse students earlier in their training. For Diploma students they will experience a good balance between sufficient theory to match the clinical experience that forms a core part of their programme.

Each lecturer has a responsibility for a subject area depending on their clinical background. Here they are hard at work devising lesson plans for units in their subject (below). This work is the start of building a bank of accessible documents for use by all lecturing staff both full and part time. I wish them well in their endeavours as I head back to the UK this week. KSLP will continue to support the role of nurse educator at COMAHS so watch this space for updates!

Happy World AIDS Day!

Our infectious diseases volunteer Hannah unravels the complex picture of HIV in Sierra Leone and explains how KSLP are supporting the National HIV/AIDS Control Programme to improve diagnostics and testing.

 

Happy World AIDS Day. Maybe an odd thing to say on a day that commemorates a disease which has killed 70 million people worldwide. But despite the ongoing tragedy of the HIV pandemic, in 2017 there is lots to celebrate.

While a vaccine or a cure remain distant prospects, we now have incredibly effective treatment for HIV. Antiretroviral therapy (ART) can suppress the activity of the virus in the body to the point that it is undetectable and people show absolutely no symptoms or signs of the disease. Many people living with HIV can now take a single, well-tolerated pill each day, and live a normal healthy life. Perhaps even more impressively, we now understand that people with HIV who are taking effective treatment with a suppressed viral load cannot transmit the virus to other people.

With such powerful weapons to fight this disease, reversing the growth of the pandemic now seems possible. UNAIDS has adopted the ambitious 90-90-90 targets – that by 2020, 90% of people living with HIV should know their status, 90% of those should be on treatment, and 90% of those on treatment should have a suppressed viral load. This has driven a huge global scale-up of ART provision, and data from severely-affected countries such as Swaziland is beginning to show the benefits.

So what about Sierra Leone? In Western Africa the picture is complex. On the one hand, fortunately, levels of infection have not reached the levels seen in Southern and Eastern Africa. Sierra Leone’s 2013 Demographic Health Survey found a prevalence of 1.5%, with up-to-date results due in 2018. However, the lower burden of infection means that HIV has previously been afforded a lower priority and less international donor support than in other countries. There is an increasing recognition that Western and Central Africa are being “left out” of the HIV progress seen elsewhere in the continent.

The problem is multifactorial. In the highest-burden countries, almost everyone will know a friend or neighbour who is affected by HIV, which has some effect on normalising the disease. In Sierra Leone, despite the support of counsellors and peer networks, the majority of people living with HIV have not disclosed their status to anyone, for fear of discrimination or even abandonment. As a result, many people believe HIV to be a rare problem, or one that is confined to certain marginalised groups such as men who have sex with men or commercial sex workers. Most sexually-active young adults do not perceive themselves as being at risk of infection, and condom use is low. Fear of HIV affects testing rates, while infected people who are hiding their HIV status from their families find it very difficult to access care and take treatment regularly.

While ART medications are provided free to patients through the Global Fund, people living with HIV face multiple other barriers to care. Limited human and physical resources mean that patients may have to travel some distance to an ART site, and the cost in time and money may be prohibitive. In the rainy season, it can be difficult for supplies to reach remote clinics and stock-outs may occur. This is particularly problematic because excellent adherence is required for ART to successfully suppress the virus. Missed doses because of stock-outs or financial problems, or interruption of care during the Ebola outbreak, can lead to irreversible drug resistance developing.

This formidable challenge means that many people living with HIV in Sierra Leone are not benefiting from prompt diagnosis and effective suppressive ART, and instead develop weakened immune systems and infections such as tuberculosis and cryptococcal meningitis. People living with HIV therefore make up a very high proportion of medical inpatients in Connaught Hospital, with associated high mortality.

Recognising the scale of the challenge facing Sierra Leone, in 2017 the National HIV/AIDS Secretariat launched the ambitious “Catch Up Plan”, which aims to rapidly scale-up HIV testing and treatment across the country. Along with other NGOs, KSLP has been working with the National HIV/AIDS Control Programme to support implementation of the plan.

As part of the national HIV Technical Working Group, KSLP members have been centrally involved in updating the 2017 ART Guidelines to reflec,t the WHO’s 2015 “Test and Treat” recommendation – that all people living with HIV should initiate ART, rather than just those who have evidence of a weakened immune system. We have also been supporting national training sessions on these new guidelines for HIV workers across Sierra Leone, mentoring and supervising staff in Connaught to ensure their implementation, and working on translating these guidelines into a more accessible format which can be disseminated by smartphone app.

In Connaught we have been working with the hospital management and HIV counsellors to increase testing through provider-initiated testing and counselling for patients attending the hospital. This strategy, which is recommended by the WHO, takes advantage of a person’s contact with health services to offer them HIV testing, regardless of the reason for presentation. This has led to a dramatic increase in the rates of HIV testing, particularly amongst medical inpatients. We support care for these inpatients through clinical work with the junior doctors and regular HIV ward rounds with Connaught’s clinicians, and by improving systems to promote access to important tests such as CD4 and TB screening. We are collaborating with a local infectious disease specialist to pilot screening for cryptococcal disease in HIV patients with advanced immunosuppression , and to learn more about the prevalence of cryptococcosis in Sierra Leone.

Treating HIV in Sierra Leone can involve witnessing a tragic loss of young lives when people present with very advanced disease. However, the amazing effects of the treatment mean that it can also be extremely rewarding. A few months ago, I reviewed a lady in her twenties who presented with speech difficulty and complete paralysis of the right side of her body. She had initially been diagnosed with a stroke, but when her admission HIV test was positive we decided to treat her empirically for cerebral toxoplasmosis, a parasitic brain infection seen in people with advanced HIV. The improvement was remarkable. She regained her ability to walk and talk, started ART, and now just has some mild hand weakness. I regularly bump into her and her mother waiting outside the physiotherapy department for her appointment, gaining weight and looking healthy.

In addition to individual success stories there is definite progress following the Catch Up Plan, on both concrete targets and more subtle indicators. When I first arrived in Sierra Leone in January I found many people reluctant to talk about HIV. Healthcare workers adopt euphemistic acronyms – RVS (retroviral syndrome) or ISD (immunosuppressive disease) rather than utter those other three letters. One of the aims of provider-initiated HIV testing was to normalise HIV as “just another disease”, like hypertension or diabetes. Now it feels like the dialogue is changing, with a noticeable increase in awareness and willingness to discuss the problem. Connaught’s young doctors are passionate advocates for their HIV patients, and gain a lot of knowledge and experience about HIV management. While there is still a long way to go in tackling stigma, it feels like people are talking more openly about it.

HIV progress starts with openness and advocacy. So, Happy World AIDS Day! Celebrate by telling one other person the news that people who are on treatment with a suppressed viral load live a normal healthy life and are unable to transmit the virus. We’re looking forward to continuing to work with Connaught and the National HIV/AIDS Secretariat to make that a reality for more people living with HIV in Sierra Leone.

Hannah and Dr Lakoh teaching a session on scaling up HIV services across Sierra Leone last week.

Antibiotic Awareness Week: Guideline Launch!


In this post, our infectious diseases volunteer Imogen offers some insight into the issue of antimicrobial resistance in Sierra Leone and describes the antimicrobial guidelines project which was launched during World Antibiotic Awareness Week.

 

 

This week is World Antibiotic Awareness Week and around the world there has been a focus on promoting both awareness of antimicrobial resistance and the need for antimicrobial stewardship, i.e. responsible usage by clinicians and patients alike. During this time, the KSLP infectious diseases team oversaw the launch of the University of Sierra Leone Teaching Hospitals Complex (USLTHC) Connaught Hospital Anti Microbial Guideline. This is the fruit of over a year’s work, drawing on expertise from a variety of local and international partners. We hope this will be a useful reference for junior doctors at Connaught Hospital, who requested guidelines like these to improve their ability in prescribing as they report not much formal teaching about prescribing in their undergraduate training. Following graduation, they bear huge levels of responsibility, especially as due to well documented human resource constraints, they can find themselves operating fairly independently very early in their careers.

Audit data from Connaught Hospital from March 2016 showed that 76% of medical admissions through the emergency department were prescribed antibiotics, and of those prescribed, 88% had an inappropriate dose, route or frequency. It is evident there was a clear need for simple guidance to help those who provide frontline medical services here with prescribing decisions around this crucial area, especially when it is known that the use of broad spectrum antibiotics (those that target a number of different types of bacteria) drives resistance.  This guideline serves as the first formal promotion of antimicrobial stewardship in Sierra Leone but there is much more work to be done – firstly, in improving surveillance data. Without a robust laboratory service in the country, anti-microbial resistance goes largely unrecognised with an ‘out of sight, out of mind’ attitude. However, we know there is widespread, indiscriminate use of broad spectrum antibiotics (e.g ciprofloxacin and ceftriaxone) in the community, so it is unsurprising that worrying levels of resistance are starting to be seen with improved surveillance.

The guidelines were drafted by a committee of clinical and pharmacists from Connaught Hospital and KSLP, drawing on national and international guidelines, and local resistance data (where available). The draft was reviewed by stakeholders in Sierra Leone as well as KSLP technical advisors based in the UK, before being presented to the Drugs and Therapeutics Committee at Connaught Hospital. We know the guideline is not perfect, but we hope the recommendations are an improvement on the current practice. One major constraint is the lack of reliable local sensitivity data, and also data about what are the prevalent pathogens. Consideration was given not only to likely pathogens and resistance mechanisms, but also the affordability of drugs to patients – in the interests of best antimicrobial stewardship principles, we would like to always recommend the most narrow spectrum option available for any given condition, but from our experience in clinical practice, we know if this means going from a once daily administered drug to a four times a day administered drug, the price may quadruple, and become unaffordable.

Tests to confirm diagnosis, either pathological or radiological, are also expensive, and therefore a luxury the junior doctors often have to do without. For this reason, we have not emphasised the antibiotic review in this first edition of the guideline as this principle relies so much on good diagnostic support. This principle states that the antibiotics should be reviewed ideally at 48 hours to see if they can be stopped, changed or stepped down from IV to oral.  We have encouraged oral step down, but if there is no additional information to confirm or refute an assumed diagnosis, it is difficult to advocate strongly the other courses of action. In addition, there is the recognition that counterfeit drugs are common in this part of the world, so it is easy to blame the drugs rather than the bugs if the patient is not improving. As a doctor, it is a disheartening environment in which to practice medicine, as you rarely get feedback on whether the right course of action was taken, making it difficult to learn and improve in the crucial early postgraduate stages of training.

It was decided to make use of the smartphone app format, making the resource easily accessible to junior doctors (who all have a smartphone, or perhaps even more than one) and reducing the risk of the documents deteriorating in quality over the years or indeed going missing altogether as we often see in the UK too! To achieve this, we worked with Essential Medical Guidance, based in South Africa, who agreed to host the content on their platform. We hope that using this format will allow changes to be made to content as surveillance data and knowledge evolves in Sierra Leone. We’re very grateful for their support in hosting the guidelines and adapting into the app format and are very proud of the outcome. If the implementation and dissemination is successful then we hope to develop similar guidelines for internal medicine and opportunistic infections which can also be hosted through the Essential Medicine Guidance platform.

So after many months of work, this week we finally launched the app, accompanied by a training session for junior doctors at Connaught Hospital to provide an introduction to antimicrobial resistance and stewardship as well as the functionality of the app. The initial feedback from Junior Doctors was very positive. This launch event also facilitated dialogue between senior clinicians and members of the Pharmacy Board of Sierra Leone, who are leading the delivery of the National Strategic Plan for Combating Antimicrobial Resistance.

Looking to the future, the next steps will be to promote use of the app during mentoring sessions with the junior doctors, complete another audit after implementation, and ultimately continue to develop the ongoing research capacity building projects which are essential to generate local resistance data and inform the next iteration of the guideline. It is also essential to recognise the importance of infection prevention and control (IPC)  – with a reduced level of infections there will be less need for antibiotic use. During the launch of the guidelines, we took the opportunity to strengthen messages around IPC best practices, reminding doctors that IPC exists not only to protect the workforce from the patients, but vice versa as well. Ultimately, we hope that by developing a culture of antimicrobial stewardship in Connaught Hospital, it will be possible to reduce the emergence of antimicrobial resistant infections and consequently reduce avoidable deaths from hospital and community acquired infections.

You can read more about antimicrobial resistance on the WHO website – http://www.who.int/antimicrobial-resistance/en/

And you can also make your stewardship pledge and become an Antibiotic Guardian here – http://antibioticguardian.com

Life in Freetown

 by Linda Jenkins, KSLP Nurse Educator

 

 

I came to Freetown in August 2016 hoping to use my training skills and nursing/midwifery knowledge to work with partners at the faculty of nursing but wasn’t at all sure what the role entailed as I was this was the first KSLP volunteer post in nurse education. Joining a team of skilled medical volunteers seemed daunting at first, but the sense of camaraderie and fun was good as we adjusted to conditions and challenges but also enjoyed the benefits of Salone life (beaches, bars and fresh fish & seafood). I found common ground with some of the nurses who had worked through the Ebola epidemic which helped us create a voice for nursing amongst the medics and researchers!

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It is strange for me to feel that though it’s been many years since I worked in West Africa (I spent three years in a village in Burkina and two in The Gambia) some things are still the same – the heat; the noise; the colours; the music; the pace of life. The welcome for us all is big here although the country has suffered a great deal. Before I arrived, I had some insights through listening to my partner who has spent many years working with Sierra Leone Red Cross and from my daughter who spent time here too. My colleagues at the faculty of nursing are inventive when dealing with the challenges that face them – poor conditions in offices and classrooms; no electricity or water and plenty of students. They accepted me as a partner and I enjoyed getting to know them as friends too. I feel having experience of living in Africa helped me and them to communicate and build relationships, which is the core to partnership working. There are naturally challenges for me and for them. For me it’s taking time to understand and see how things work. It’s never time wasted. For them it’s understanding that Kings doesn’t always bring money but offers skills and connections.

There is no doubt the role that Kings played during Ebola created a positive attitude towards Kings volunteers and this helps forge relationships. I’ve both enjoyed and been frustrated when working here but possibly no more than in my previous NHS role! The work on the curriculum development, sharing the frustrations of the nursing lecturers, meeting the students and invigilating at exams are all highlights of my working time here. The beaches, developing a suntan and being able to work near my partner were highlights of my home life here. There are plenty of outlets for activities outside work like beach walks, (watching) running, swimming, bars and a large international church group to be involved with. As anywhere in low resource countries, it’s getting your head around the obvious contrasts in contexts of poverty and the rural/urban split that is hard. Despite this, the experience is huge and rewarding.

We are currently looking for a new Nurse Educator to replace Linda as she moves onto pastures new – please check our Volunteer page for more details. To apply, please submit a covering letter (maximum 2 pages) and CV (maximum 4 pages) to volunteer@kslp.org.uk before midnight on Sunday 24th September.

Designing a Development Programme for the Faculty of Nursing Lecturers

The King’s Sierra Leone Partnership is moving into an exciting phase with our partners at the Faculty of Nursing at the College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone.

On 3rd November 2016, Sister Alicia Wilson-Taylor, Senior Nurse Lecturer at COMAHS, and Dr Matthew Vandy, Dean of the Faculty, co-led an interactive workshop with the support of Linda Jenkins, KSLP’s Nurse Educator. The workshop built on teaching sessions started with COMAHS in 2013/14, before the Ebola outbreak halted this work, and outlined current plans to design a development programme for the faculty of nursing lecturers.

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Topics of discussion included developing skills in carrying out teaching observations, peer evaluation of teaching, student assessment, ward teaching, research, and the use of IT. The session was attended by 8 of the faculty lecturers.

Sister Wilson-Taylor shared with the group an inspiring example of using interactive learning in a teaching session the previous day where students had been asked to work in pairs to define the characteristics of a nurse and feedback to the group. Sister Wilson-Taylor said the session had been very successful and that the students came up with great ideas and the team is looking forward to future sessions.

kslp-and-faculty-of-nursing-at-comahs-photo-1 Dr Vandy, Sister Wilson-Taylor, and colleagues will be working over the next 10 months, supported by Linda, to develop the nursing curriculum, teaching, and assessment methods and use the learning from similar work that has already taken place in the Faculty of Medicine, also supported by KSLP’s Education Manager Suzanne Thomas.

IPC Campaign Week

As part of our ongoing work with the Infection Prevention & Control (IPC) Programme, KSLP IPC nurse mentors have been supporting partners at Connaught, Lumley and King Harman Road Hospitals to implement regular IPC campaign weeks. These weeks have proven effective in building and maintaining enthusiasm among hospital staff about the importance of following IPC protocols.

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Hand washing during one of Connaught’s IPC weeks in May

Each IPC week is different, but typically each day of the week has a particular theme for which the IPC Focal Person collaborates with the link nurses to focus the day’s training and monitoring on one particular component of IPC.

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Bobson Fofanah explaining the correct disposal of sharps

For instance, this September featured Sharps Safety Day at King Harman Road Hospital. Assistant IPC Focal Person Bobson Fofanah visited each ward to ensure that sharps bins were assembled correctly and located in safe places in each ward. He also checked to see if there are instructional posters in place and to make sure every staff member is aware of the importance of proper sharps disposal.

IPC campaign weeks build a strong sense of teamwork and enthusiasm about IPC across the hospitals. The week ends with a celebration, with awards given to the wards showing improvement in IPC practices.

IPC weeks also give the team opportunities to show off their creativity!

King Harman Road Nurses sing the IPC Song from King’s Sierra Leone Partnership on Vimeo.