I have a Bachelor of Science in Nursing and I work as a Registered Nurse in a specialized Gastrointestinal Oncology ward and Outpatient Chemotherapy unit at Rigshospitalet, Copenhagen. When I was a nursing student I was a volunteer at the Danish Youth Red Cross for two years as a project coordinator and this is where my interest in International work began.
Before I decided to join NTR, I spent almost a year looking for the right project/organization to join. I didn´t want to be part of a “fly-in, fly out” general volunteering project, I wanted what I worked on to be specific to my specialized skill set and to be sustainable after I leave. I like NTRs concept of educating nursing preceptors, so they have the skills and knowledge to teach the junior and senior nursing staff, and when they are ready, run the project themselves.
I like the fact that you have to work hard, have loads of self-discipline, and you are in charge of bringing your own ideas forward, that turn NTR’s goals into reality- all in coorperation with the hospital’s management, policy and procedures. I also like that it is not an organization that is about taking condescending photos of the staff and environment and posting it on Facebook but rather about developing the nurses’ knowledge, so they can pass it on.
Four weeks ago I started volunteering for NTR in B.P. Koirala Memorial Cancer Hospital in Bharatpur, Chitwan, Nepal and I will be volunteering here for three months. My focus will be to teaching nursing preceptors in areas such as medical oncology: safety handling procedures for chemotherapy treatments; emergencies in oncology; and, time permitting, training in A-G assessments. I am working with these areas because previous surveys done by NTR, show that these are the areas that need work. I am NTR’s first nurse with specific experience in medical oncology and chemotherapy, so I will be starting this project from scratch, which will be interesting and a challenge!
I started my first week with several meetings with nursing supervisors, to discuss our expectations, and what sometimes seemed most important - to drink Nepali tea. It strikes me to be very important to meet the most senior nurses first. The hierarchy needs to be respected if I want approval to work in the ward.
I created a pre-survey regarding chemotherapy to get a feeling about the nurses’ knowledge about preparation, administration, handling of cytotoxics. The survey and observation period created a good baseline, and means I can focus on areas that need further development. The surveys showed that the majority of the nurses know some of the theories behind working with chemotherapy. However, during my observation period, I discovered that they don´t know how to bring the theories to practice, and they don´t quite understand how dangerous hazardous drugs can be if they are not handled with care.
I am so happy to see them wear Personal Protective Equipment (PPE), and prepare chemotherapy in a Biological Safety Cabinet (BSC). They have a dedicated fridge for cytotoxic drugs, and all the nurses receive bed-side training in chemotherapy, before they are allowed to do this alone. This is great!
They have a basic frame to work from, which is a good start, but since they started providing chemotherapy, there have been so many new updates that have not been implemented. Ultimately, I am impressed with the protocols that are in place, considering the limited resources.
1. PPE is provided for nurses and they are very good with wearing it routinely. However, they don’t always wear the PPE correctly, and the correct PPE is not always provided. According to the management this because it is a low resource country, and some of the correct PPE is not available in Nepal. I will look into this together with the nursing director! It might be straightforward to provide for them.
2. Here in Nepal it is the family that provide basic care for the admitted cancer patient. They bring food, wash the patient, help the patient to get body fluids from bed to bathroom when the patient is too weak, etc. They do all this without any PPE, which means that they are at risk of being exposed to hazardous material from the family member receiving chemotherapy.
3. A lot of the cytotoxics used in the ward is only totally excreted after 6-7 days, but in the hospital’s guideline a guide of only 48 hours is given as the guidelines have not been updated following the introduction of new chemotherapy regimes.
4. The same PPE is worn to prepare and administer chemotherapy, possibly spreading cytotoxic material around the whole ward.
5. While the staff should be commended on cleaning the BSC each day, there appears to be a lack knowledge on how to do this properly. Each time I checked, I could see cytotoxic waste on the inside and outside of the BSC. Exposing the staff member preparing the chemotherapy with bare ankles and feet in sandals.
6. The patients’ drugs are at risk of being contaminated, because the room also is a storage room where patients’ family members gets blankets, wheelchairs, etc. The cleaning staff clean the room during preparation, and use the same mop through the whole ward, potentially spreading hazardous drugs.
Some times I find it quite frustrating that it is a very specialized hospital, they have CT-scanners, perform complicated operations, and gives complicated cytotoxic treatment to patients, but don´t have the proper PPE for the staff!!!
One day during my observation, one of the junior nurses ask me why I want to work in a poor country like Nepal, when I come from a country with free health care, and advanced hospitals. It made me stop and think a bit further about it. My answer to her was a short explanation of the health risks that she was currently being exposed to. She looked at me with a new and concerned expression in her face, looked down on her bare arms where she was holding the chemotherapy bottles that had visible chemo left on the outside. She said: ”This is not good…Thank you didi”.
I am even more motivated to get started after talking to the Senior Nursing Supervisors. They told me that several of the nurses working with preparation of cytotoxics have mentioned serious health problems like hair loss, dizziness, rash, and one has even been send to a specialist, because of an abnormal blood test. The environment is a serious health risk for the staff.
All this might seem negative, but the ward’s management seems very interested in having an update in their knowledge about cytotoxics, so they can pass it on to their staff. This is positive, and the best start!
I hope I can be creative with the resources that they have, and make it safer for the nursing staff to work there, and for the patients to receive chemotherapy.
I will write an update in a couple of weeks again!