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.

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.

Partnership for change: first impressions in Freetown

I’d always wanted to volunteer in a developing country, motivated like many by an interest in applying my skills to help a place in great need. I was attracted to the strong partnership ethos of King’s Sierra Leone Partnership (KSLP) and delighted to have the chance to come and work with Connaught Hospital colleagues.

I joined the NHS as a graduate general management trainee in 2009, after which I worked in various operational and strategic roles including most recently as Programme Director for Diabetes & Stroke Prevention at Health Innovation Network (HIN), the South London Academic Health Science Network. I am grateful to my managers at HIN for kindly allowing me a six month career break to come to KSLP in Freetown.

During my first month at Connaught I was struck by how hospital life is on the one hand of course so totally different, and yet on the other hand many of the issues are similar to the ones that NHS managers devote their careers to solving.

laura-at-connaughtProbably the most striking difference is the spectrum of common diseases. Infectious diseases (such as TB, malaria, HIV, measles, meningitis, pneumonia and others) are very prevalent. Spending time observing in an outpatient clinic during my second week here I was also taken aback by the severity of advanced disease that Connaught staff are treating. In my years in UK hospitals I have never seen so many patients so poorly as I have seen here in just a few weeks.

But while there is what sometimes feels like an overwhelming amount of suffering, there is also a good deal of hope. Patients, relatives and staff are incredibly warm and friendly, greeting strangers they pass in the corridor and one person who I hadn’t met before thanked me profusely for my work! I have met some incredibly strong and resilient people here who have survived some terrible times and are committed to working towards a better healthcare system. The work they do every day is truly impressive and humbling, particularly when you remember that they have far fewer resources of all types than we do in the NHS.

The issues that Connaught has in common with the NHS that I’ve discovered so far are as follows (I’m sure there are more!):

  1. Issues around flow of patients through the hospital – together with Connaught doctors and nurses we’ve started some process mapping to better understand the problems before co-designing solutions
  2. Rotas and handover processes
  3. Ways to embed effective multi-disciplinary working
  4. Estates and maintenance issues
  5. Effective management of outpatient services and ensuring patients do not become lost to follow up
  6. Health records management
  7. Robust systems for audit and quality improvement

And it’s the last two issues where I am focussing my energies for now.

There’s a great deal of enthusiasm in the hospital for improving the health records system, both to improve patient safety and care quality as well as enabling staff to undertake meaningful clinical audits and quality improvement projects. The records office staff in particular are fantastic and we have been working together on the first stages of our improvement plan.

It’s also a fascinating process working with colleagues to start up a rolling programme of quality improvement projects. We’ve established a committee where projects can be proposed, registered and reported on when completed. Our first two projects are about implementing the new international guidelines for the treatment of malaria and improving antibiotic prescribing. We’re going to be running some multi-disciplinary training sessions soon on quality improvement tools and methods. I am learning a lot from colleagues here showing me what is likely to be effective and what is not, and why.

My third project is an evaluation of a major educational programme working with the medical, nursing and pharmacy schools at the College of Medical and Allied Health Sciences (COMAHS). I’m developing some new skills in designing qualitative evaluations and it will be interesting to hear the views of staff and students in the focus groups and interviews early next year.

I’ve always thought that the role of an effective healthcare manager is to provide the best possible environment and conditions for clinicians and patients, so that the best possible patient outcomes are achieved. This means making sure that systems work and that staff have the right skills, equipment and support to meet patients’ needs. As one of my first managers in the NHS memorably put it, “you have to be the glue” that brings the various parts of the system together. These principles are exactly the same here. I’m enjoying learning about how the Connaught management team is approaching this task and trying to make the best contribution I can.

Volunteering overseas is a “less trodden path” for healthcare managers than it is for clinicians, but I would encourage anyone who has an interest to pursue it and get in touch via volunteer@kslp.org.uk if you would like to know more. Whilst there are some tough times, it’s an incredible and very worthwhile experience.

Laura Spratling, Hospital management volunteer