I arrived back in Montreal a month a go and as I write this last web entry, I recall fondly my time spent in Njombe. Working with our Tanzanian colleagues at TANWAT was an exceptional personal and professional experience. I would like to take this opportunity to express my gratitude to Highlands Hope and, particularly, Madeleine Buck and Christina Clausen from McGill Nurses for Highlands Hope for providing this astounding opportunity. Also, this project would not have been possible without the participation and mentoring of Betty Liduke. Asante sana. Last, I would like to acknowledge the participation of the nurses and the medical officers at TANWAT; their motivation to be involved in this project and excitement in working together was stimulating and contributed to the success of the pain education module. Asanteni sana.
According to the expressed interest of the nurses at TANWAT, the overall pre-departure objective of this project was to pilot a first education module on pain assessment and management in pediatrics (see web entry November 8th 2007). As soon as we began to develop the module, the health care professionals at TANWAT were involved in determining its format and content. A series of short pain workshops was identified to be most appropriate as previous professionals development activities in this setting had been implemented using this format.
To determine the workshops content, the staff's pain information preferences and approach to pain management were explored in more depth by conducting individual interviews, a group discussion, and regular clinical observations, particularly when participating in the morning rounds. In addition, questionnaires, including a pre-workshop pain knowledge survey, were distributed to nurses at TANWAT and Ikonda.
Specific questions explored included: "If a pain seminar is offered to nurses, what topics do you think should be included? What strategies do you use to alleviate/decrease pain? What types of pain are most often seen? How do you determine if a patient is in pain?" Together, the information gathered was integrated in the planning, implementation, and evaluation of the workshops.
Health care professionals identified pain as the most common symptom they face in their daily practice. Although an interest for pain in both adults and children was identified; a particular importance was given to pain in pediatrics as health care professionals felt a strong responsibility in recognizing when the extent of a child's pain might go unrecognized due to children's limited communication skills. Additional topics of interest included: identification of pain, types of pain, neurophysiology of pain, and pharmacological and non-pharmacological management of pain.
Accordingly, four pain workshops were developed:
1) pain assessment part 1: definition of pain, types of pain (e.g., neuropathic pain, referred pain), myths and misconceptions, and pain assessment in adults, including use of pain measurement tools,
2) pain assessment part 2: pediatric pain assessment and non-pharmacological strategies for procedural pain,
3) pain neurophysiology and non-pharmacological strategies, and
4) pain management principles and pharmacological strategies with a particular focus on reviewing the World Health Organization analgesic ladder.
Each workshop lasted between 60 and 90 minutes. Learning strategies used consisted of didactic lectures to discuss the main topics and provide new information, flip charts to facilitate communication, providing Power Point handouts with detailed information about the topics discussed, and presentation of clinical cases and role plays inspired from practice. In addition, I was regularly present in the clinical setting to further support the integration of knowledge and to determine, with nurses, the applicability of learnt skills to patient care.
Clinical outcomes of the workshops included integration of pain as the 5th vital sign, adaptation and use of a pain assessment documentation sheet, use of pain measurement tools, and implementation of some non-pharmacological strategies for minimizing procedural pain in children. Feedback questionnaires were distributed to workshop participants and overall comments were positive, particularly the use of role play, and allocating enough time to practice new skills was favored.
This was my first trip to Africa, and although I had tried to prepare in many ways, I really did not know what to expect. My journey to Njombe was exhilarating and exceeded all possible objectives I may have had. I brought back many souvenirs from Africa, however those that are most precious to me, were not the ones packed in my suitcases.
During my stay at TANWAT, I was particularly inspired by the enthusiasm of the staff to embark upon this project. Despite an already busy schedule and managing daily care challenges, the nurses and medical officers were willing to participate in the planning of the workshops. It is through these exchanges that we learned how we should go about implementing the workshops and how we can combine our experiences to make it happen. It is also through these exchanges that relationships were forged and led to going above and beyond to ensure that the workshops would benefit everyone.
The most important lesson I take away is: "just listen". At times, it might be challenging to "just listen", without responding or offering a "solution" or making comparisons with our own approach to care. I think "just listening" permitted a more in-depth exploration of perspectives and it invited others to provide suggestions and directions. The pain resources that I had brought with me were helpful, but the conversations with the other health care professionals provided the most important information upon which to develop the project.
Listening takes time (pole pole) and sometimes it might feel like one is standing still or even moving backward, however I realized, in the end, we were moving forward even faster than I thought.
Shukrani zangu kwa wafanyakazi wote wa TANWAT kwa kushiriki kwenu na kunisaidia katika maandalizi ya warsha yetu. Asanteni sana.
McGill Nurses for Highlands Hope