Final Days within the Philippines

On our last day of clinical we participated in a mass immunization for a measles outbreak occurring in Mayamot Elementary School.

This was followed by a culminating activity to sum up our experiences of the past month. Here we were able to share many of our personal experiences and stories with the Filipino nursing students and faculty. The Dean’s of nursing from St. Paul’s University, University of the

Philippines, and University of East Ramon were all able to speak to us in regards to the global partnership being built between our schools and their hopes to continue this relationship for years to come. Lorna Butler, the University of Saskatchewan’s Dean of Nursing, was at hand to voice our desire to maintain a strong bond in the future. As nursing students, we feel this experience has impacted how we will practice in the future and therefore strongly believe in maintaining this partnership for the benefit of future NEPS students.

As this experience marked our last day in clinical, the time has finally come to close our blog. The past six weeks have offered ample learning opportunities in regards to community health care delivery within the Philippines. It also provided us with the chance to grasp a greater understanding and appreciation of the Filipino culture. Not only did we learn a lot about a very unique and interesting population, but we also learned a lot about ourselves along the way. One of the most valuable lessons we will take away from this experience is learning how to work effectively as a team. Considering we spent a lot of “quality” time together throughout the past month we learned quickly the importance of becoming a functional team member. Knowing how to work effectively as a team member is a valuable quality to have as a nurse and we feel this experience has aided us in developing this quality.

We would now like to take this opportunity to thank all of those who helped facilitate our time in the Philippines. These include, but are not limited to, the Dean’s of nursing Dr. J. Tuazon, UPM, Dr. C. Divinagracia, UERMMMC, and Sr. Carolina Agravante, SPC, President, St. Paul Univeristy, Iloilo, all of whom welcomed us into their schools whole heartedly. Also, the many faculty members who helped us receive an extraordinary clinical experience, including Jerry, Ruby, Mrs. Lim, Ms. Castro, Ms. Mollo, and Zandro. You were all amazing and taught us so much, thanks! We would like to extend another huge thank you to all of the nursing students who acted as our “buddies” and our personal translators while working in the community. We have formed new and lasting friendships and are looking forward to maintaining these contacts in the future. Thanks goes out to Lorna Butler from the University of Saskatchewan, who helped make this trip possible, as well as our instructor Susan Fowler-Kerry who believed in us enough to allow us to partake in this experience. Lastly, thank you to all of those who followed our blog and took interest in sharing our experiences. We bid you adieu.

Top picture: Ashley and Melissa preparing syringes with the measles vaccine.

Middle picture: Nursing student performing the Filipino Tinikling dance.

Bottom picture: (top-bottom, left-right) Bethel, Ashley, Sr. Carolina Agravante, Dr. C. Divinagracia, Lorna Butler, Dr. J. Tuazon, Kirsten, Ms. Molo, Mrs. Lim, Ruby, Chelsea, Melissa, Joelle, Whitney and Jessica

East Ramon / Antipolo

February 1 - 3, 2010

February 1st marked our last day in Ilo Ilo city. Our plane left at 12:45 and we began our journey to the University of East Ramon (UERMMMCI). Here we met up with the Dean of Nursing from the University of Saskatchewan, Lorna Butler and were orientated to our planned activities for the week. We were paired off with UERM nursing students and we had a chance to get to know each other. Later, we were invited to an alumni dinner where we enjoyed a variety of entertainment and delicious food. We then travelled to St. Michael's Retreat House in Antipolo, which is our home base for the week.

February 2nd began with courtesy calls starting with Dr. Antonio G. Reillo, the Manicipal Health Officer of Antipolo. He provided us with information regarding Antipolo's health care system. The area is populated by 700 000 people and is staffed with 6 nurses, 7 doctors and 200 barangay health care workers to meet this large populations health needs. This further illustrates how thinly stretched health care workers are within Filipino communities. Next we visited the Assistant Superintendent of the Department of Education, Maria Luz Salvador who welcomed us to the community.

Our next activity took us to Sta. Cruz Elementary School where we assisted 4th year nursing students in testing children's eyesight. The school has 7292 children ranging from grades 1 to 6. Due to the abundance of students enrolled at Sta. Cruz, they are taught in 2 different shifts organized into 6 hour blocks. This occurs because it is not possible to accommodate all of them at once. The goal of today's activity was to assess the eyesight of Grade 2 students using the Snellen visual acuity chart. Visual impairment can be one of the many reasons for poor academic achievement in school aged children (Karande & Kulkarni, 2005). Administering eye exams allows health care providers to rule out visual impairment as an indicator of poor school performance. Early detection of visual impairment is a good example of primary health care, as diagnosis can greatly improve their quality of learning. We observed several children who demonstrated the less than desired 20/20 vision, with one of the worst cases presenting as 70/20. After diagnosis, the UERM students will be working on fundraising in order to provide glasses for the children who need them.

In the afternoon we were able to observe health teaching and activities provided by the UERM nursing students. The activities reinforced learning on environmental health and safety, physical activity and proper diet and nutrition.

February 3rd we visited a geriatric centre. Here we were given the opportunity to socialize and interact with senior citizens of the community. Positive social interaction is therapeutic in recovering from illness and essential in maintaining morale (Stephens, Kinney, Norris & Ritchie, 1987). This centre provides elderly clients within the community both access to health teaching and activities, planned and implemented by 4th year nursing students. Our experience demonstrated the positive results of socialization as the elderly clients enthusiastically participated in activities and built relationships with others. We were able to participate in activities such as, dancing, singing and charades. This experience was memorable for both the people of the community and ourselves.

After visiting the geriatric centre, we participated in an immunization clinic. Here, we were able to immunize infants who were scheduled for DPT, Hepatitis B, OPV and measles. There were approximately 50 infants present at the clinic who commuted from surrounding barangays.

In the afternoon, we joined medical students and barangay health workers for an organized socialization. Here, we had the opportunity to ask questions regarding their role within the community health setting. We were able to observe how UERM nursing and medical students interact side by side.

First Picture: Ashley McDonald with 4th year UERM nursing students

Second Picture: Courtesy call to Dr. Antonio G. Reillo's office

Third Picture: Joelle using Snellen's visual acuity chart

Fourth Picture: Melissa giving instruction to a student

Fifth Picture: Group picture at the geriatric centre

Sixth Picture: Having fun with the UERM nursing and medical students

Medical-Surgical Mission

Friday, January 29, 2010

St. Paul’s University went the extra mile to provide allow us to experience a clinic focusing on prenatal care and pediatric circumcisions. This was a medical mission established for the school, providing an opportunity for male community members between the ages of 9 and 14 to receive free circumcisions. Circumcisions are recommended for all males in the Philippines in order to prevent infections from swimming in contaminated water supplies, improve hygiene, and decrease the prevalence of sexually transmitted infections.





Pictured:

1. The surgical room where circumcisions were performed.
2. Kirsten ready to assist with a circumcision.
3. Our team with the medical doctor who performed the circumcisions.

Birthing Experience at a Rural Health Unit (RHU)

Tuesday, January 26, 2010

After labouring over fire and coals for three hours, we were able to enjoy a “Canadian” meal with our Filipino friends. It was a challenging task having to cook for 22 people, and we were all covered in sweat and soot by the end, but it was a rewarding experience to share part of our culture with the students since they have shared so much with us.

Following dinner, we began getting ready for bed, and received a call at 2100h from a midwife at the RHU clinic regarding a delivery that we were invited to attend. Jessica, Kirsten, Ashley, and Whitney quickly changed and ran (literally) to the clinic to participate in the delivery.

When we arrived at the clinic, we discovered that there were two women labouring: one primpara who was in active labour, and one multipara who was walking around the clinic trying to progress through the labour process in a natural manner. While assisting in the two deliveries, we learned that at the RHU clinic all women deliver without analgesic. Also, labour is augmented through rubbing the woman’s nipples, stimulating the production of oxytocin, which enhances uterine contractions. Furthermore, 10U of oxytocin is administered IM following the delivery of the placenta.

From both lecture content and personal experience in the delivery room, we have noted that in Canada many women receive epidural analgesic during labour and delivery, are given IV syntocinon to augment uterine contractions, and receive additional oxytocin IM following the delivery of the baby’s anterior shoulder. Masking pain related to childbirth and augmenting contractions through synthetic pharmacological methods can be referred to as “medicalization”. Parry (2008) refers to medicalization as changing normal bodily states and processes into complicated, pathological events. Furthermore, Parry (2008) asserts that medicalization occurs when a biomedical field perceives natural life events such as labour and delivery to be risky and dangerous. Through experiencing traditional deliveries in a rural health center, we have come to appreciate the benefits of natural rather than medicalized birthing methods. This is because in Canada, the focus of labour and delivery has become viewed as a process of treating an illness state, which medical professionals are trained to “…determine, control, and rectify…” (Parry, 2008, p. 786). By approaching the birthing process as something that needs to be fixed or controlled, the success of the delivery and overall family experience can be negatively affected.

After experiencing two natural deliveries, we can see positive aspects that could be implemented in Canada. Some of these include: shifting our focus from progressing through the stages of labour in a timely manner to assisting and coaching the mother in transitioning through her personal birthing experience; and decreasing the overuse of pharmacological treatments during the birthing process. This would create a more meaningful and family-centered life event.

Overall, this was a very exciting and rewarding experience since some of us have never experienced or assisted with deliveries before. We would like to thank the midwives, clinical instructors, and students for going the extra mile to make this experience possible!

Pictured:

1. Whitney and Chelsea helping prepare the "Canadian" meal.

2. Jovan, Irina, Arielle, and Jessica wearing their labour and delivery scrubs waiting for the second delivery.

3. The birthing stretchers in the delivery room.

4. Infant assessment area and bassinette in the delivery room.

References

Parry, D. C. (2008). “We wanted a birth experience, not a medical experience”: exploring Canadian women’s use of midwifery. Department of Recreation and Leisure Studies, University of Waterloo, Waterloo, Canada 29, 784–806.

Janiuay

January 25th to 28th


The morning of January 25th we left Iloilo with the St. Paul's nursing students and travelled to the province of Janiuay. This was a unique week as we were going to be living with the students at the university's staff house. There were 22 people staying at the staff house, including both groups of students, two faculty members from SPU, Dr. Mahli Brindamour and Dr. Ryan Meili, from Saskatoon. While staying at the staff house the students took turns with cooking and cleaning duties. This was a new experience for us as we not only had to learn how to cook Filipino dishes and buy food from the market, but also how to cook over an open coal fire.

While in Janiuay we spent our mornings in Rural Health Unit (RHU) which is the main health center for this area. RHU provides many different services within a small facility. We were paired up with our buddies at different stations and were able to rotate posts throughout the week. Some of our experiences including working at the IMCI desk, the assessment area, the prenatal area, treatment room which included immunizations and wound dressings, and consultations with the doctors. This clinic also includes a labour and delivery room where we were on call during our time in Janiuay.

When clients arrive at the clinic they are first seen at the assessment desk. At this station we take the client's vital signs, chief complaint, history, and then do a focused assessment. Anyone under the age of five years old is managed through IMCI, anyone over five years is seen by the doctor. This was exciting for us because in Canada we have not yet had the opportunity to be the first person doing the initial assessment. Some of the cases consisted of hypertension, cold and fever, breast pain with a possible lump, abdominal pain, diarrhea, nausea and ear pain. Considering we are Canadian students who do not speak the native languages of the Philippines, we relied heavily on our buddies to assist us with all of our interactions with clients. "Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm" (Leonard, Graham, Bonacum, 2004). We also had to rely more on the clients non-verbal communication in an attempt to pick up anything missed in translation.

At the IMCI station we used the standardized framework to further assess all children under 5 years old. If the child is showing any of the 4 danger signs (convulsions, vomits everything, not able to drink or breastfeed, or abnormally sleepy or difficult to awaken) they will be seen by the doctor. If not they are diagnosed, treated and cared for by the nurses. The different conditions which IMCI is assessing includes measles, dengue hemorrhagic fever, malnutrition and anemia, ear problems, fever, malaria, and diarrhea. The most common cases we saw were cough and fever.

We were able to work along side Dr. Mahli Brindamour and Dr. Ryan Meili during their consultations with patients. This is something that we rarely have the opportunity to do in Saskatchewan, so we are very grateful. During this time the doctors also relied on the SPU students for translation. Some of the cases observed were patients with a cough and cold, hypertension, kidney infections, query pneumonia, infected wounds, and dengue fever. The positive diagnosis of dengue fever was achieved though the tourniquet test. This was our first opportunity to ever observe this test.

During our prenatal assessments we were able to further advance our skills. Here we took the mothers blood pressure, measured fundal heights, auscultated the fetus's heart rate, did Leopold's maneuvers, and gave the mother necessary tetanus injections.

In the treatment area we were able to give many immunizations. Here we were able to give injections children under 5, which we have not had the opportunity to do in Canada. Some of he injections included Hepatitis B, measles, tetanus, DPT (diphtheria, pertussis and typhoid). We also got to administer the oral polio vaccine. There were also many wounds we were able to clean and dress.

Our afternoons were spent in Sitio Asinan and Sitio Gamad, which are 2 Barangays in Juniuay. Here we chose one family in which we did a complete family assessment. We assessed such things as living conditions, medical history, income, education levels, work life, spirituality, physical and mental status, relationships, community involvement, and what the community feel they need most. These families were extremely welcoming not only to the Filipino students but also to us. We also went into other homes to assess vital signs.
One of the major problems we observed in these communities was the lack of toilet facilities, running water and proper garbage disposal. The majority of the parents within the community had a low level of education and some of the children were not attending school. These families had small incomes which made it difficult to purchase food and proper footwear. The combination of all of these determinants increases the risk of contracting parasites and infections (Nematian, Nematian, Gholamrezanezhad & Asgari, 2004).


On our last day in the community we held an assembly for both of the Barangays. At the assembly we had all of the guest register which included checking vital signs, as well as heights and weight of those under 5 years. The Canadian students created a modified version of snakes and ladders which included health teachings the children. The Filipino students were responsible for creating a game for the mothers. We also participated in role playing to help teach the mothers proper parenting regarding feeding. This assembly helps the Filipino students, who will be working in these Barangays in the next several weeks, evaluate the health status and needs of the communities. Following the games we performed a dance to the popular song, ‘nobody’ and handed out healthy snacks for everyone.



Thursday, January 28th we spent the morning presenting research to each other on different health concerns prevalent in the Philippines. In the afternoon we attended Januiay's festival and then travelled back to Iloilo.

Top picture: Us in our Iloilo uniforms
Second picture: Kirsten, Chelsea and JP doing wound care
Third picture: Melissa assessing a family
Bottom picture: Us playing our game with the children at the assembly

Arriving in Iloilo

January 21st-24th, 2010

We've made it to Iloilo save and sound after our brief relaxtion period in El Nido. Sister Carol and the rest of St. Paul's University (SPU) has welcomed us into the community with open arms and hearts. We have spent the last few days becoming acquainted with not only the students and faculty, but also the community at large.

January 21st
We were invited to dinner with the Sister's of St. Paul's and had the chance to try several Filipino dishes, including delicious Mango ice cream. We also met our "buddy" students, who we will be partnered with throughout our community immersion in Janiuay next week. The students include: John Paul (J.P), Arielle, Tanya, Jovan, Stella, Kaye, Clecile, Irina, Diane, and Valerie. Faculty who are aiding in the facilitation of this experience include, Ruby Ann Duguesa, Maria Thelma Servidad, Dulce Ma Tilos, Vanessa Traje, and Ma Lalaine Nolasce, and of course Sister's of St. Paul's. We also joined the company of Dr. Ryan Meili and Dr. Mahli Brindamour, both affiliated with the University Saskatchewan and will be participating in our Janiuay experience.


January 22nd
The day began with visits to various local community members. Susan R. Cuevas (RN, MN, Nurse VI) informed us about several nutrition initiatives within the Iloilo community. A quick visit to the Department of Health allowed us to meet Ariel L. Valencia (M.D), the current Regional Health Officer. The DOH is in charge of various initiatives, which adhere to WHO standards, such as DOTS, HIV/AIDS program, and immunization/vaccination clinics. The DOH is highly focused on outreach programs and increasing healthcare access for Iloilo's growing population. While visiting the DOH we were able to tour the cold room, where they store the vaccinations according to WHO standards.

We met the Governor of Iloilo, Neil D. Tupas SR, who welcomed us to the community and provided us with tickets to the Dinagyang Fiesta 2010. This fiesta is celebrated every fourth weekend of January to honor the Christianization of the natives and to respect the Holy Child Jesus.

In the afternoon we traveled to Janiuay (an hour outside of Iloilo) to tour the community. This involved visiting the staff house (our home for next week) and Dr. Bienvenido P. Margarico, mayor of Janiuay.

January 23rd
We were orientated to St. Paul's College of Nursing and their BSN curriculum. The aim of their program is to develop values, attitudes, knowledge and skills. St. Paul's nursing students also encompass the competencies of a caring, creative, contemplative, critical, and collegial nurse. Throughout this orientation we noted several similarities between both the St.Pau'ls BSN program and the U of S BSN program. Although both programs are span over four years the St. Paul's nursing students enter a common freshman program consisting of generalized classes before they offically enter the nursing program. This means they have the opportunity to "soul search" before commiting to becoming a nurse. Another key difference we noted between the two programs was that St. Paul's nursing students have the opportunity to act as charge nurse on a ward, in their fourth year, to apply knowledge and theory acquired in their management and leadership course. We felt this would be a useful within our own program, as it helps to clarify nursing responsibilities and further develop management/organizational skills.

In the afternoon we had a presentation on IMCI (Integrated Management of Childhood Illnesses). This is a strategy developed by WHO to aid developing countries in treating childhood illnesses within outpatient settings (WHO, 2008). The program has two main objectives: 1) Decrease the global mortality and morbidity rates of children and 2) Increase healthy growth and development of children worldwide. It is currently being utilized by Iloilo community health nurses, and the nursing students of St. Paul's University, to help treat children suffering acute respiratory infections, fever, diarrhea, ear problems and malnutrition.

"Every year in the world's developing countries, approximately 12 million children under the age of 5 die of illnesses that have been controlled or overcome by developed countries" (SciELO Public Health, 1997). Considering the Philippines is a developing nation this tool is very helpful within the community of Iloilo, which continues to experiecence high numbers of childhood mortality and morbidity. The IMCI trains nurses in basic assessment and classification of common childhood illnesses within the region. Physicians are therefore not required to do the initial assessment and have time to deal with a greater number of cases. The IMCI follows a case management process which allows the nurse to assess, classify, identify treatment options, treat/refer to physician, counsel, and follow-up. (Somewhat resembling the nursing process).

Learning about this classification tool was very helpful and informative, as it is used to identify many illnesses not commonly seen in Canada. This includes illnesses such as malaria, measles, typhoid, dengue, pertussis and dysentry. We are looking forward to putting this new knowledge into practice while in Januiay in the upcoming week and will be having several debriefing sessions to discuss our observations regarding exposure to such diseases. The knowledge we have obtained from this experience has been beneficial to all of us and we will be able to apply it in future nursing practice, regardless of the setting.

January 24th
Sister Carol kindly extended an invitation to St. Paul's Sunday Morning Mass, which we accepted. Following mass, we were able to attend the Dinagyang Fiesta tribal dance competition. It was an amazing experience which allowed us to observe several traditional tribes from Iloilo area. As more and more tribes from Barangays, schools, and nearby towns and provinces participate, the contest has become more competitive in terms of costumes, choreography, and sounds.

Top picture: U of S Nursing Students with Sister Carol

Middle picture: St. Paul's and U of S Nursing Students and Faculty

Bottom picture : Dancers at the Dinagyang Fiesta 2010

El Nido, Palawan

January 17th-20th, 2010


On January 17th we got on a 19-passenger plane and went to Miniloc Island Resort in El Nido for a short vacation. The resort was absolutely beautiful. While we were threre we did various activities such as snorkeling, beach volleyball, island hopping, sea kayaking, watched and participated in a cultural show, and took in the numerous sights. Here are some pictures for your enjoyment!

Our resort!

Another view!

On our way into the Big Lagoon.

Our view from one of the islands.

Building Fred the turtle.

Us in the limestone caves.