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Bronwen Griffiths and Ange Gittus are Clinical Nurse Specialists in Emergency in Northern NSW. Angie has just completed her MPH (Tropical Medicine) and Bronwen tutors for the MPH program at Syd Uni. Brady Tassicker is a FACEM in Tasmania who spent a year in Kiribati in 2016.

 

When Brady Tassicker stood up at the 2015 Emergency Care Conference and asked if there were any nurses in the audience interested in offering to provide an emergency nursing component in support of the year-long medical training program he was intending to run in Kiribati, we signed up without hesitation.

 

Apart from knowing that it was a small Pacific nation rendered vulnerable by climate change, we knew little about Kiribati; however we were both looking for a new project, and intrigued by the prospect of a multidisciplinary collaboration that combined our shared emergency nursing and international health backgrounds.

 

We stayed in touch with Brady as he moved to Tarawa and catalogued the challenges and rewards of the working environment at Tungaru Central Hospital. While wrestling with the financial logistics of getting ourselves over to Kiribati on unpaid leave, we received the news that the Director of NZ company Ross Road Marking was in Tarawa when one of his employees had a serious illness, and was so grateful for Brady’s efforts in expediting a retrieval that he had asked if there was anything he could do in return. Sponsoring a pair of emergency nurses to get to Tarawa for a month was probably not the request he expected, but he did so very cheerfully, and we found ourselves working in the Tungaru Central Hospital ED in August 2016.

 

Kiribati is a nation of scattered atolls and islands spread across 3.5 million square kilometres of the Central Pacific, bringing unique challenges to its national health system. The main island of South Tarawa is a long thin series of causeway-linked atolls that sticks out like a pincer into the ocean, curving as part of a wider land mass around a giant lagoon. This small stripe of roughly 15 square kilometres somehow contains almost half of the country’s 100,000 people, with a population density similar to Hong Kong, but with none of the corresponding infrastructure. Tungaru Central Hospital (TCH), the country’s largest referral hospital, is one of the country’s only providers of tertiary care, and sees large numbers of high acuity patients both from South Tarawa, and from the Outer Islands.

 

The chronic overcrowding in the ED is exacerbated by a lack of structure in the built environment - there is no Triage area and no Resus, patients simply present to one of two beds at the entrance to the unit and are mostly seen in the order in which they arrive. If they need further treatment they are then moved to one of the dozen beds inside the unit, or if waiting to be admitted, moved to a larger overflow area outside the rear of the department.

 

A further complication of an environment with so many manifest barriers to process and flow is that Kiribati has a policy of continuous nurse rotation to make up for the chronic nurse shortages in the workforce. This means that the Nurse Unit Manager is the only nurse permanently assigned to the department, and the development of the cohesive team based culture so essential in the emergency environment is rendered almost impossible due to constant staff turnover.

 

What we did find on this initial trip was that there were a significant group of nurses who were very keen to work in the ED as often as they were able to be assigned there, and who were extremely motivated to undergo further frontline training. In fact, enthusiasm for education ran across all nursing areas, and the rather impromptu bi weekly training sessions we held soon ran out of chairs.

 

The nursing administration at TCH are refreshingly open to ideas and strongly supportive of their nursing staff. They could already see that for the ED to advance in the future that the nursing staff needed a skills training program that went beyond the recent (and very welcome) inclusion of nurses in visiting medical courses such as Primary Trauma Care and Advanced Life Support.

Accessing nursing education in Kiribati, is however, easier said than done. Midwifery, which is currently the only recognized hospital specialty in nursing, requires post graduate training to be done in Fiji. Other nurse training programs have involved individual nurses traveling to study overseas and returning to the country with skills that may not be readily applicable to either the health burden of the country or the low resource hospital and clinic environment.

For emergency nurses to be able to leave the rotation system and remain in the ED, both the aspiring nurses and the Director of Nursing felt that the basis for a career pathway needed to be established, in which a specialised introductory education program could be the first step towards a future diploma of emergency nursing. After discussion around the logistics and the shape of the training program that the nurses wanted and the administration considered practicable, we promised to come back with a modular program that would be accredited by an outside institution and provide the first step in the pathway towards emergency nursing as a specialty. The program would be divided into two parts, with the initial course focussed on assessment and recognition of a sick patient, and the second part introducing triage, advanced assessment and the deteriorating patient. Owing to the current lack of a triage space at TCH, it was agreed that funding would only be sourced initially for the first part of the program.

The Australian College of Emergency Nursing agreed to accredit the course we outlined with CPD points, and shortly after we started the development process, we were able to access the new WHO Basic Emergency Care Course (BEC), which provided a bedrock of the ABCDE assessment skills which formed the heart of the program. Our own supporting material was designed and written to provide background to the BEC content, and also to specifically address issues relevant to the Kiribati emergency nursing environment, including acute local presentations such as fish poisoning and in depth coverage of NCD’s.  ISBAR was incorporated as a structured communication tool to facilitate effective handover and escalation of clinical concerns.

By this time Brady and his family had completed their year in Tarawa, so there was no opportunity to develop a synchronous medical and nursing training program. The three of us nevertheless continued to collaborate on a submission to the International Development Fund Grant (IDFG) of ACEM and were fortunate enough to receive funding for the duly named Kiribati Emergency Nurse Training Program (KENTP), which was subsequently rolled out in May 2017. (‘Rolled out’ being a term that doesn’t quite describe the tottering arrival of 100kgs of training manuals, indestructible wheeled sphygmo units for TCH ED, and our rather battered family of manikins)

We had decided that with only two of us, 16 nurses was the maximum group number that would still allow a hands on focus, so the Principal Nursing Officers (PNO’s) who manage the rostering and rotation process selected 12 nurses from TCH and 4 from Betio, the smaller hospital at the other end of the Island. We were also approached by the Kiribati School of Nursing (KSN) to include a number of their lecturers, so we breathed a sigh of relief at having brought two extra training manuals and squeezed two extra members into to the group to finish with a total of 18 participants.

Although the course only ran for nine full days, we allowed six weeks in country to ensure that not only would the participants have lead-in time with the material, but also that the course could be run at a pace that allowed the already tight staffing to be managed without undue risk. Nursing administration settled on a three day a week format as being one that was manageable, and we allowed an extra day at the end for re-testing (which we didn’t need). In keeping with the multidisciplinary approach, and to facilitate consistency, training in the use of the ISBAR communication tool was also provided to the interns through the Kiribati Intern Training Program (KITP)

The support given to the program by the PNO’s and senior nursing administration was absolutely central to its success. Despite the difficulties of removing 16 nurses from what was already very tight rostering, the PNO’s ensured that all the nurses were able to attend every one of the education days, and that hospital transport would be available to facilitate this. They also ensured that enough food to keep a small army on the move would turn up for the nurses at regular intervals, and they personally prepared dishes catering to the unusual food preferences of the presenters (we are both vegetarian, which is not something that fits easily in a country so fond of chicken and pork and so lacking in vegetables).

The nurses worked extremely hard to accommodate their shifts around the study days and many worked afternoon shifts after full days of lessons as well as weekends and night shifts. Many nurses also had families and babies or young children to care for on top of their study and work load, and the dedicated mother of one of our students brought her baby in to class twice a day to be breastfed.

The course was designed to be as hands on and interactive as possible, with the first half of the day being lectures and discussion and the second half practice and simulation. Both the BEC slides and the supplementary topics had been printed as part of the workbook to lessen the need for note taking, although most of the workbooks were impressively annotated by the end of the course, and some already had a colourful frill of cross referenced post-it notes before we started.

Final testing was both written and practical, with a multi-choice exam in the same format as the pre-test, and an OSCE based around structured assessment and handover using ISBAR.
Students demonstrated steady improvement throughout the course, both qualitatively (observed performance in simulations and communication) and quantitatively in formal testing. Informal quiz testing on each new subject area ensured that core information was being accurately received on a topic by topic basis, and final scores show an impressive trajectory from the pre-test to the final exam, in which all students received either distinction or high distinction.

 

The OSCE component showed an even more dramatic improvement, as the majority of students had never been exposed to simulation before the course and many found the concept initially very daunting. Watching their confidence and enjoyment in the Team Leader role grow over the three weeks was one of the (many) highlights of our experience in Tarawa.

Anonymous written evaluations confirmed the high level of engagement demonstrated throughout the course and an enthusiastic commitment to ongoing training, particularly in the acquisition of triage skills.

The graduation ceremony that completed the course was a wonderful celebration of the effort and dedication that both nurses and nursing administration had contributed to the training. In keeping with local tradition, specially designed graduation garments were created for the event, and despite the selected fabric only appearing a few days before the ceremony, somehow everyone managed to appear resplendently in an individually designed outfit, to receive their certificate and a course lapel badge from the Permanent Secretary for the Minister of Health. A wide representation of hospital management attended the ceremony, as did Dr Tanebu Tong, the doctor in charge of the ED.

In a heartening confirmation that the skills and enthusiasm shown throughout the course weren’t diluted by hangovers from the post-graduation parties, the Director of Nursing emailed us some  weeks after our return to Australia. She relayed a number of successful ‘saves’ by the new and now permanent ED nursing team, and commented on how they all want to work out the front with the sickest patients to keep their skills up.

Funding and infrastructure are, as ever, the two biggest elephants in the room. We would love to go back and complete the training program in Kiribati, however concrete plans for restructuring of the Emergency Department are still many years away. How many of the KENTP nurses will still be working in the department by the time triage training is available, and how well maintained their initial skills will be are both issues of concern. Nursing administration would like to see the introduction of a two to three day Train the Trainer course encompassing assessment and communication training that would allow emergency nurses to become a resource for developing the frontline skills for nurses and Medical Assistants on the Outer Islands, but realistically this will also need to wait until it can be tagged on to the second stage of the training program.

In the meantime, we are setting up a website and linked facebook page to assist in building and maintaining momentum around emergency nursing in the Pacific and to allow the exchange of ideas and stories to support people working in this fledgling space. Although traditionally the funding priorities have been medical in their focus, it makes both practical and economic sense to support nurses in gaining the frontline skills they need to effectively prioritise their care in an environment increasingly focussed on climate related disaster preparation. These are tools that will benefit whole communities, and there is certainly no shortage of nurses with the enthusiasm and motivation to take them up.

 

We feel very grateful that Brady has given so much of his time and support to a project designed by and for nurses, and that the College of Emergency Medicine awarded the funding that made the course a reality - allowing a fantastic group of clinicians in Kiribati to be able to call themselves ‘Emergency Nurses’ for the first time..