FNN Member Travels
IAFN Members Mentor Healthcare Providers in Swaziland, Africa - Influence Incremental, Yet Important Changes
By Daria Waszak, RN MSN CEN COHN-S
Kim Nash only had a few months to get ready and didn’t know much about what to expect – just to pack her bags and prepare for a trip of a lifetime.
Nash was invited to complete an eight-week assignment in Swaziland, Africa along with fellow pediatric forensic nurse, Megan Lechner. Their mission: to improve the care for children who survive rape. But Swaziland’s social problems and inapt practices left challenges far greater than Nash imagined.
“What was most surprising was their lack of primary needs: water, food and education – the purposeful oppression of the people to maintain the king’s lifestyle,” explained Nash, BSN, RN, SANE-A, SANE-P, Memorial Hospital, University of Colorado Health, Colorado Springs, Colo. “The social issues were the hardest for me.”
Swaziland is a small, landlocked country next to South Africa with a monarchy government where most people live in poverty, and life expectancy is only 50 years (compared to 79 years in the U.S.). In 2012, Swaziland had the highest prevalence of HIV/AIDS of any country in the world with about 26 percent of adults infected. The US Agency of International Aid (USAID) and IAFN teamed up to send American forensic nurses there to mentor Swazi healthcare providers on the best practices for pediatric sexual assault examinations and HIV prophylaxis.
Lechner, MSN, RN, CNS, SANE-A, SANE-P, Memorial Hospital, University of Colorado Health, was Nash’s colleague and made a perfect companion. They are both experts in pediatric forensic practices and already knew how to work with one another smoothly. They had an incredible amount of support from their husbands, employer, and IAFN to make the trip happen.
“I am so glad I had the courage to do it,” said Nash, who had never heard of Swaziland before this project. “It was incredible.”
After an exhausting two days of travel, Nash and Lechner made it to Swaziland. Throughout their stay, the duo was culturally coached by their driver, Timothy, who often explained customs on route. For example, you never offer anything with your left hand, as it is a sign of disrespect.
“It shocked me how much it looked like home – seeing the mountains, but then I’d see a monkey and realize I’m in Africa,” Nash remembered of her first sights of Swaziland. “There were contrasting images and ideas. There could be a really unique plant, a giraffe, or a mountain, then I’d see something heartbreaking, like a child starving in the street.”
Nash and Lechner spent their first few weeks completing a needs assessment; they visited 17 settings in multiple sites throughout all the regions of Swaziland. Nash explained Swaziland has no real system for child protection, welfare, food stamps, or alimony, and overflowing orphanages that are difficult to get into. So many parents had died from AIDS, leaving children in the care of grandparents or extended family members who may not be ready to take them in. She discovered that even when mothers were present, they may be stuck in an abusive situation or struggling to find food and water for their children.
“One mother begged us to take her children back with us to America,” Nash recalled.
For their final five weeks, Nash and Lechner stayed in one location, Raleigh-Fitkin Memorial Hospital in Manzini, Swaziland. “We chose a hospital in an urban setting that had pediatric rape patients and nurses who wanted to learn,” Nash explained. “Little, shared taxi vans, called Kombi, brought rural people into the urban areas.” They brought HIV prophylaxis for themselves – just in case of an accidental exposure, but were pleasantly surprised to find an adequate supply of HIV pharmaceuticals as well as an understanding of their administration. “The biggest obstacle (with HIV prophylaxis) is the same as in the U.S.,” Nash said, “patient compliance with 28 days of medication.”
They monitored and educated the nurses, social workers, and physicians who were working with the sexual assault patients and encouraged belief and support in the victims. Using a mentorship approach, they asked questions to prompt critical thinking, provided direction, and observed demonstration of tasks.
“Most physicians were very interested,” Nash said. “I think we did a good job.” Nash explained Swaziland’s very different practices for pediatric victim examinations. Their social worker took a history mainly to judge veracity, and physicians attempted to estimate virginity during vaginal examination.
The virginity checks were discussed carefully and with a lot of thought and time. “It was a delicate process determining how to address the inaccuracy that you cannot medically determine virginity,”
Nash said. Evidence is not typically collected in Swaziland because Nash said there is no crime lab in the country. “I don’t think evidentiary exams are the most important piece for Swaziland,” Lechner explained. “There is no way for them to store the evidence or pay to send them to South Africa to have them analyzed. They simply do not have the infrastructure to support this. I think they need to refocus their priorities from evidence collection to appropriate medical exams and social support.”
Nash and Lechner saw 14 pediatric sexual assault victims during their stay. One of them was a boy, about 7-years old, who reported a history of sodomy. “They didn’t recognize sodomy as rape,” Nash said. “I couldn’t find a provider to see the little boy. I finally convinced a surgeon to do it. “ The facility had no electricity, so Nash cleverly used the light from her iPhone to help the surgeon visualize the anus during the anal examination. They were not able to see any injuries. “The surgeon wrote ‘no evidence of rape’ on the police form,” Nash said. “I asked him questions to make him think and write it in a different way.” The surgeon recognized how his wording implies the boy is lying and agreed the sodomy could have occurred and left no visible injuries.
Teaching how to document more accurately was one of Nash’s small victories. Another win was helping healthcare providers coordinate with one another to improve history collection and avoid having the victim repeat the same things to different people.
Through workshops, they also helped dispel some of Swaziland’s extraordinary myths about rape, such as, an HIV-infected adult having intercourse with an HIV-free child will cure them of the disease. “There is so much work to be done,” Nash said. “We didn’t make big changes. It was hard for me to take a step back and realize I have to make small changes.” Nash had a difficult time leaving Swaziland knowing the help that is needed, but couldn’t wait to return to her two children.
She has a new appreciation of systems in place in America. “We have child protection, trained firemen, police, laws, and child support,” Nash listed. “They may not be perfect, but we have them in place.” She will never forget the experiences in Swaziland: the sights of the Swazi culture, the children who had never seen a photo of themselves, over-ordering dinner every night at the hotel so the waiters could take food for themselves, and even their driver, who Nash said she thinks about every day.
“I would go back again in a heartbeat, if they asked me to,” she said. Lechner is just as willing to return to Swaziland. “In eight weeks, we didn’t get done what we thought we might,” Lechner said. “These healthcare providers need continued education and support. Additionally, we only mentored providers at one hospital. There is an entire country that needs assistance.”
IAFN Member Helps Rebuild Nursing Foundation at a Hospital in Kuching, Malaysia
By Daria Waszak, RN MSN CEN COHN-S
IAFN member, Joyce Williams, traveled to Malaysia for her first work abroad, but this was not a one-week sharing of forensic knowledge. This was a six-month stay where she was able to thoughtfully assess and improve basics of nursing practice at a hospital. Williams, D.N.P., AFN-BC, DF-IAFN, SANE-A, D-AMBDI, Assistant Professor, Stevenson University, Owings Mills, MD has a broad gamut of specialty knowledge to offer, but understood the importance of building a strong nursing foundation first.
“Malaysia and the hospital where I consulted were looking to improve the competency levels of the nursing department,” Williams said. “I provided all types of training to the leadership in the nursing department and offered expertise on a variety of nursing issues. Before forensic nursing can be integrated, much groundwork had to be established.”
She first learned of the job through an e-mail she received from a consulting company.
“They are a very good private hospital with a well established record which is why they have many international patients and contracts with businesses and mission groups,” Williams explained. “They believe in a high level of patient care so they look to consultants to help them achieve that.”
Williams was immediately interested and discussed it with her husband. She obtained the appropriate university permissions, interviewed, and met face to face with the consulting company, and interviewed with the Malaysian hospital via Skype.
“I looked at the request as an opportunity to utilize my knowledge and expertise and share it with a community wanting to improve nursing and patient care,” Williams recalled.
The hospital, located in Kuching, is in a community with many shopping areas, temples, and opens green space. It is an Islamic country and has a mix of Chinese, Malay, and other ethnicities.
“When I first arrived, I thought it looked poor,” said Williams who commented on the apartment buildings with clothes hanging out to dry and prevalence of small, old cars and motorbikes (scooters). “It is common to see an entire family of 3-5 people on the back of a motorbike.”
The hospital arranged her transportation between work and her housing- an air-conditioned 3-bedroom apartment on the 12th floor in a gated and guarded complex that had a swimming pool, lake and clubhouse. Williams said she always felt safe.
“The people are extremely friendly and quite easy to get along with whether shopping, eating out or with any encounter,” she said. “The people are happy with their lifestyle and never complain. They are very religious putting their God above anything else. While some of them would like to own a house or have a nicer car, they keep a positive attitude about life.”
Williams started her journey trying to understand the full scope of resources and competency levels.
“The first month was spent conducting a needs assessment to understand the nurses, how they worked and what works as well as what is missing,” she explained. “From there I began working on unit objectives and conducted some training to improve the delivery of care and collaborative practice.”
On a typical day, Williams would make rounds on various wards to learn about the patients or review the case notes with the nurse or intern to evaluate their understanding of the patient conditions. She rarely passed anyone without a warm hello. The nurses spoke English, and she found they had very high standards of care.
“Their infection control nurse made rounds on all patients with wounds, evaluated skin breakdown and all patients with dressings,” Williams said. “Their dialysis unit was extremely busy, and the clinics provided same day appointments as many patients came from a distance (Indonesia) to have the services of a private hospital as opposed to a government hospital where the cost was minimal, but often had long waits under crowded conditions.”
She worked with the Directors of Nursing on how to improve nursing care using evidenced-based practice and collaboration with the medical team.
“This is a very friendly community with staff and patients welcoming and accepting knowledge and advise from a fellow nurse,” Williams said. “They look to me for information and how to improve services to patients and the holistic care, a part of their mission.”
Most of the nurses there were diploma nurses, but some had obtained their BSN or specialty certificates known as “post basic” training.
“The initiation of staff development and education department is in its infancy with an unlimited growth potential providing services and training to all of nursing as well as collaborating services,” she explained. “They are interested in higher education and hope to build a SON in the near future.”
Williams completed a recruitment and retention plan, strengthened the internship program, and established a nursing staff development department to support the nurses with continuing education.
“The thank-yous are extremely rewarding as well as the smiles that cross the faces of all staff,” she said of the cordial atmosphere. “The opportunity allows me to provide assistance to a growing healthcare community and to share my knowledge. It has been extremely rewarding.”
And although Williams was away from her husband, son and daughter for six months, two of them were able to visit during her stay and they traveled to Bali, Thailand, Kuala Lumpur and Kota Kinabalu.
As the hospital’s nursing foundation is restructured and enriched, improved screenings and assessment of victims of violence and other opportunities for growth in forensic nursing can emerge.
“Forensic nursing is very new, and in the six months I was only able to touch the surface of evaluating intentional injuries,” she added. “This will be more important as the consultation continues over time.”
She completed her six month assignment in Kuching in December 2013; there are negotiations in place to continue the work over the next several years. Short and long term assignments may also be available for other nurses.
“After the first few weeks, I found this culture to be a home away from home,” Williams said. “I have made long-lasting friends who will remain close to me. I anticipate that we will work together continuing the momentum that has been created in the short time that I have been here.”
International Assocation of Forensic Nurses Member Impart Forensic Knowledge and Practices in Peru
By Daria Waszak, RN MSN CEN
Ruth Downing first met “Nina” at a Peruvian farmland shelter for the sexually abused. Nina was 14 and holding her 2-month-old son. She had become pregnant from one of her abusers.
“She was very proud of her baby - but appeared sad and tired,” recalled Downing, MSN, RN, CNP, SANE-A, President of Forensic Healthcare Consulting, Columbus, Ohio. “She was with another 14-year-old girl at the shelter also carrying an infant.”
Paz y Esparanza, a Christian human rights organization, provided Nina, and other girls like her, with a safe place to live and education while investigating their sexual abuse cases. Downing’s altruistic and rewarding contributions in Peru include working with a team of dedicated professionals to share forensic practices and witness progress, but some of her most memorable moments are those meeting the very people she was there to help. Tears came down her eyes when she saw Nina again three years later.
“She would look for me and proudly show me her adorable son, with his round face and jet-black hair,” Downing said. “Her smile was now spontaneous and she seemed very happy. Her baby was full of energy and played with the other children at the shelter.”
According to statistics collected by the United National Office on Drugs and Crime, from 2005-2009, Peru had the highest rate of rape in South America. And Downing described the corruption in their justice system, which she explained may even include some judges.
“Although Peruvian laws address child sexual abuse and sentences often include life in prison, these cases are rarely taken seriously,” Downing said. “Few perpetrators are held accountable, and few victims obtain justice.”
In 2008, Downing was first called to join the collaborative mission with Paz y Esparanza, and their partners, The River Church Community from San Jose, CA and the International Justice Mission. She joined pastors, social workers, teachers, law enforcement and other professionals to visit Huánuco, a poor region of central Peru with dirt streets just over the snowcapped Andes Mountains. It is accessible from a 90-minute, 12-seat propeller airplane ride from Lima.
"I was blown away,” Downing said of her first international travel. “They put me in front of people, and I just starting talking.”
Downing traveled with constant protection of law enforcement to ensure her safety. It was a full week of 11-hour days training Peruvians– through an interpreter - on sexual assault evidence collection. And she has returned every year since.
“It is a life-changing experience every time I go back,” Downing said. “The information that we have to share with people is like gold to them.”
After realizing Peru wanted to focus more on child sexual abuse, Downing went to the IAFN conference and grabbed former IAFN President, Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN.
“When in Peru, I teach forensic physicians, as well as psychologists, and government agents (e.g., police, lawyers, judges) charged with adjudicating cases of child abuse, trafficking and domestic violence,” said Speck, Associate Professor and Forensic Nursing Option Coordinator, University of Tennessee Health Science Center College of Nursing.
“I create teaching materials in response to the topic requests from the Peruvians. These materials focus on a health care response through a forensic lens that builds on their knowledge, skills, abilities and resources - which are few.”
Over the years, their team has trained a plethora of people how to deal with child sexual abuse and domestic violence issues - including judges, prosecutors, forensic physicians, law enforcement, social workers, advocates, teachers and even parents. They haven’t educated nurses yet, but hope to create that opportunity in the future. “We emphasize that we don’t have all the answers, but to share what we know,” Downing said. “They take it and make it their own.” She is amazed at how much the Peruvians have done just that. Downing recalls first learning about their forensic practices. “Their documentation of sexual abuse was solely based on if she (the victim) is deflowered (hymen intact),” she said. “That is what they based their whole evaluation on. We had to gently help them through that.” Downing and her team were able to tour the facility used by the forensic physicians. She described it as a concrete building on a back dirt road. One of the rooms in the building was large enough for a desk and a very old exam table.
“This is where the exams were done,” Downing said. “Down the hallway was the morgue. We made a gentle comment of how nice it would be if the morgue was separate from the exam area.”
She said the next year they saw they had built a wall separating the morgue from the examination area. There have been improvements in their equipment as well. “I brought cameras, hooked them up to their computers, and demonstrated their use to help build evidence of a crime,” Speck said. “I’ve cleaned microscopes covered with volcanic dust, and after classes, discussed difficult cases with teams of professionals, always focused on their limited resources and cultural responses to the materials.”
Speck may even team up with one of the Peruvian forensic physicians to do some research. “I have been part of a wonderful interprofessional, multidisciplinary team that has seen tremendous growth in the response to violence in Peru,” Speck said. “It has been an extremely rewarding experience and validation of the expenses of my public health doctorate.”
The last few years, Downing, Speck and their team focus their time teaching in Lima, which is attended by people from all over Peru.
"I know that the trainings and encouragement provided to the judicial, legal, and medical leaders of Peru in Lima will improve justice for the many children, like (Nina) in Huánuco,” Downing said. “This is my prayer.”
Click here to support Downing’s work in Peru by purchasing a custom, champagne-flavored lipgloss http://www.forensichealthcare.com/mukha_makeup_charity.htm
Or make a donation to “The River Church” on behalf of Pat Speck. Mail to: Forensic Nursing Services, LLC, 2630 Midland Avenue, Memphis, TN 38111