As I reflect on my experiences with International Medical Aid (IMA) at Coast General Hospital, I am reminded of an ancient African proverb, “seeing is different than being told”. This priceless Internship placement with IMA has shed more light onto this age-old saying. I am still in disbelief, as I reflect on my encounters with patients, healthcare members, and health systems. Some experiences were as if they were drawn straight from Global Health textbooks, while other clinical presentations were so uncommon, it baffled even the most senior of nursing staff. In the States, I have been a practicing Nurse in the perioperative environment for over six years. However, my desire to help others globally is what initially propelled me into the nursing field since I was a young girl. This ambition, lead me to complete my Master of Global Health in 2018. However, a deeper curiosity remained, to hopefully yet experience and expand my theoretical knowledge of Global Health and Nursing. This calling eventually lead me to Mombasa, Kenya with International Medical Aid.
I came to Mombasa with a clear intention in mind. To explore whether I should pursue an advanced nursing degree in midwifery/women’s health or to pursue a non-clinical career in the Global Health field. I elected to be in the Labor Ward for 3 weeks and the Accident & Emergency (A&E) for a one-week rotation. I must report that my experience at Coast General Hospital has only complicated my decision in selecting a future career path. This internship has, therefore, taught me so much about the real experiences of the Kenyan people and their interactions within the health system. Additionally, I deepened a better understanding of who I am and what I am capable of, as I strive to contributor towards improving health globally. My clinical interactions and observations have shaped my revelations. The following paragraphs will highlight my most memorable experiences at Coast General Hospital and will subsequently uncover and provide insight into the lessons learned from each encounter.
Surprisingly, I learned that I have sparked interest in Emergency Nursing. I was drawn to the uncertainty and the variety of the clinical presentations of the patients. I admired the necessary skills to quickly and correctly assess, diagnose and treat the patient. It became apparent how important the social structure is in ensuring treatment in Kenya. For instance, a middle-aged man was brought into the emergency department semi-conscious, after being severely beaten by mob justice. I was stunned to learn that once a patient is admitted into the A&E, a family member or someone is needed to act as a “runner”. This includes providing the necessary payments to ensure the delivery of life-saving medications and treatments. This form of payment before treatment is not practiced in the United States. I was also concerned by the ethical considerations, in the lack of compassion in treating this man. Some of the doctors chastised, or even delayed his initial assessment and treatment. This form of negligence, and outspoken disdain for a patient regardless of their offenses, would be a huge breach in the ethical care of patients.
Additionally, my one week in the A&E has highlighted the gaps in the Kenyan health system. It was frustrating to witness an A&E admission where the patient was diagnosed with an active hemorrhagic stroke. There was no communal sense of urgency of the attending physician, nurses or staff. Upon asking, the staff responded with, “we are waiting for Radiology to take him for a CT Scan”. It was as if treatment was delayed or slowed down because there was nothing that the staff could do but wait for an available time for the patient to be transported to CT. The most frustrating lack of resource to see was the lack or misuse of time. Despite having a “shortage” of healthcare staff, there were not enough resources to effectively treat the patients promptly. Therefore, the quality of care suffered, and despite the medical team’s efforts in ordering appropriate treatment and care plans, there were many times where the patients’ condition deteriorated while waiting for either an ICU bed, CT Scan, surgery, etc.
Another limited resource commonly seen at Coast General Hospital was in the shortage of healthcare workers. In the States and while studying Global Health, I always heard of the healthcare workforce crisis being experienced internationally. However, it has been most prominent in low resource countries, particularly in the African continent. I admit, my understanding of this workforce shortage meant that there is not enough personnel who have successfully graduated from an accredited program. However, I soon learned that this was not the case at Coast General Hospital. During the day, there were so many students present, mostly in the form of Medical Doctors or Nurses.
I truly enjoyed my three-week rotation in the Labor Ward. Over the three weeks, I was welcomed and developed a strong rapport with the unit’s Nurses and Medical Officers. Over three weeks I developed and deepened my qualitative research and ethnography skills. I then began to ask among the varying Nurses and Medical Officers, what they believed to be their biggest frustration to be while working at Coast General Hospital. The majority of them reported “a lack of resources”. Upon further investigation, “a lack of resources” constituted as a lack of available staff and needed equipment/supplies to properly do their work. What I soon learned, was that there is not a “workforce shortage”, but rather the Government hospital’s do not have the “resources” or monetary funds to hire additional staffing. According to the World Bank, Current health expenditure (% of GDP) is 4.55 in Kenya (World Bank, 2019). This has enabled government healthcare jobs to be rare, where there are few openings for new staff, even though many nurses are looking for employment. Simply, the government hospitals cannot hire additional support staff, with a strict expenditure budget.
Understaffing of healthcare personnel can be illustrated in my experience while doing a night shift on the NewBorn Unit. There were over 42 acute babies in need of monitoring, either from experiencing respiratory distress, low birth weight, prematurity, etc. For the 42 babies, there was only 1 qualified and experienced Nurse and two student Nurses completing their internship. Within five minutes of arriving on the unit, I noticed one newborn with an enlarged hand that was bluish, white and discolored. I deduced that it was the tape that was wrongfully applied to secure the IV. Unfortunately, it acted as a tourniquet. How long had that tape been placed, cutting off the circulation supply to the newborn? I brought it to the attention of any available staff, a student nurse. I showed him and questioned him about the hand. He looked at it and said it was fine and walked away. In disbelief, I call him back again. Again, he reassured me. Being a Registered Nurse, I knew that this was not “normal”. So I eventually found the qualified Senior Nurse. I alerted her, and in frustration, she removed the IV tape and scolded the Nurse Intern.
On that night shift, I found 5 other babies with the same situation also newborns with infiltrated IVs, where their IV sites became infected. This infection was caused by medication being wrongly injected into a dislodge IV, where an assessment of the IV’s patency and placement was not conducted. It remained unclear on the future prognosis of these newborns and their limbs. This example illustrates how an understaffed unit with an overburdened workload can lead to poor care quality and outcomes. Although the staff was strained to appropriately care for these newborns 3:43, my observations in this example also illustrates the lack of staff accountability.
The lack of accountability was one of the most frustrating aspects I encountered while in Kenya. I can understand the lack of resources: staffing, supplies, time, etc. However, the lack of accountability has enabled and perpetuated a culture of error and low care standards. Not to mention, the said lack of resources of “time”, still allotted for the Nurses and Medical Officers to sleep while on a night shift. I admit that I am coming from a different culture, but being accountable also ensures that you are managing and making the most of the time given. In the States, there is no excuse to be sleeping on a shift, when you’re accountable to the health and wellbeing of your patients. I asked my fellow nurses on the unit, about this concept of accountability. To many, they did not know the word, felt shy or did not feel comfortable speaking about errors or questioning the actions or non-actions of someone more senior. Those who did recognize the unaccountable culture at Coast General contributed this to the lack of a hospital governing board and perhaps the Kenyan culture of respecting authority and age. Others spoke about the fear that arises when one openly addresses errors or mistakes of others. Even some Medical Officers reported that despite being more “senior” to the Nurses, they felt they could not report their poor care quality, in fear of the nurses “making my life hell”. There needs to be a governing body to hold the staff accountable.
Also, there needs to be continuing competency training in practice. Throughout my observations I’ve seen how there is the correct knowledge applied to a medical situation, however, there are gaps in its execution that lower the standard of care and quality. For example, a mother gave birth to a baby on the Labor Unit. The baby’s Apgar was 2/10 (floppy grimace, blue appearance, shallow and slow respirations, absent activity and heart rate below 100 bpm) at 1 min and meconium-stained liquor of 2. After the cord was cut, the nurse slowly walked with the baby to the resuscitation area, with no sense of urgency. I observed for a minute to see how the nurse would conduct this resuscitation effort. The nasal and oral suctioning performed was too superficial and not effective. There were no noxious stimuli performed to arouse or startle the baby. After a few minutes, I questioned if oxygen and bag-mask ventilation was necessary. Finally, the nurse started to show me how to ventilate a newborn. Upon observation, she was not creating a seal to ensure that oxygen was being delivered. While she thought the oxygen was being given, it was not effective as there was no chest rise and fall. I alerted her to this, and then she said you must bag the baby very fast and full, another error. In the end, together along with the Medical Officer who arrived shortly after, the baby survived (after proper resuscitation was given). This frustrating experience showed me that the healthcare personnel may know how to perform their job responsibilities in theory and practice, but there are still many errors and gaps in the execution of the intervention (i.e the knowledge to bag the baby, but implemented improperly).
This was such an incredible experience. I learned so much about myself and what I am capable of doing. I grew in my self-belief and determination to practice personal excellence. My experience in emergencies in the A&E, ICU, and Labor Ward has given me the confidence that I can act well under pressure and in fact, I enjoy it. I am a strong patient advocate. This experience has taught me that I am ready to change from practicing in the operating room to another specialty. This experience has also reinforced my passion and desire to work in Global Health. Additionally, I learned that qualitative research is valuable in understanding the social networks among people and environments, and I wish to deepen my research skills. I learned so much about myself, however, my path is still unclear. Wherever my path may lead, I know that it was guided by the experiences shared with International Medical Aid at Coast General Hospital, and for this I am grateful.