journey towards practice development for rape survivors
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Denkleiers Leading minds
Department of Nursing Science
A journey towards practice development for rape survivors
An Apprecia*ve Inquiry approach
Tanya Heyns
World Appreciative Inquiry Conference April 2012
q Rape a Global concern a Millions of people are affected annually
a Underreported by as much as 2/3
a Greatly underestimated
a South Africa? • More that 4 000 women are raped every day • One every 26 seconds
q Management principles
aSouth African government recognise challenge
aDedicated centres • Open: business hours
aEmergency units • Open: 24 hours • Private versus public sector • Focus on forensic evidence collection
Background
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q Emergency unit [ Private Level I hospital
[ Deliver emergency care to patients of all ages: neonate to geriatric patients
[ Emergencies versus trauma
[ Critically ill/injured
+
[ 560 rape survivors (25% children)
[ Approximately 46 female rape survivors per month
Setting
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q Reflecting on practice
a “…it’s going to take hours…where is Celia [nurse]…she
likes doing it…”
a “…I am not going to sit in court for days…nobody is
paying me…let somebody else do it…I will not...”
a “…I just don’t have the energy for this now…”
a “…we [health care professionals] can’t help you [female
rape survivor]…our kits [forensic evidence collection
kits] are out of stock…”
a “…we [health care professionals] cannot help you
[female rape survivor]…nobody here has the necessary
training to help you…”
Reality
4 1
Reality (cont.)
5
1
2
3
4
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ABC’s
q Focus of emergency care
[ Collection of forensic evidence [ “Ignore” female rape survivor’s needs
[ Diagnosis?
Reality (cont.)
Procedure –centred care
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Reflections on practice
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Procedure-‐centred care
Drugs
Follow-up • 3 days • 3 months • 6 months • One year
Incident
Practice development
[ continuous process of improvement
[ moving towards increased effectiveness in patient centred care
[ healthcare teams to develop their knowledge and skills [ to transform the culture and context of care
[ that reflect the perspectives of services users
q Affirmative topic
Reflection on practice
Towards Patient–centred care
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q Inductive [ Female rape survivor’s voice [ Stakeholders
• Nurse practitioners • Medical doctors • Police • Ambulance personnel • Counsellors
q Two phases
[ Phase 1: Voice of the female rape survivor [ Phase 2: Interventions towards practice development
Research methodology
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Towards Patient–centred care
q Ethical clearance…
Research methodology
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• Female rape survivor • 18 years or older • Understand and speak English • Admitted and managed in the emergency
unit (October 2010 – May 2012) • Three months after the rape incident
First contact with participant Step 1: Identify participants based on
inclusion criteria Step 2: Discuss information leaflet and
informed consent document with individual Step 3: Assess willingness of individual to participate in the study Step 4: Confirm the identity that the
individual prefer to use during contact with researcher
Step 5: Negotiate preferable date and time during which researcher can contact individual
Step 6: Provide researcher with necessary information to contact potential participant
Interview • Brief participant on aim and value of the
study • Negotiate suitable time and place for
conducting the interview • Ensure participant of confidentiality • Obtain written consent • Conduct interview
Inclusion criteria
Counsellor
Nurse practitioners
q Phase 1: Voice of the female rape survivor
[ Target population [ Sampling [ Sample size [ Data collection [ Data analysis
Research methodology
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q Phase 2: Interventions towards practice development
[ Target population
• Stakeholders
[ Sampling
[ Sample size: 36 • Nurse practitioners (16) • Medical doctors (5) • Police officers (2) • Ambulance personnel (7) • Counsellors (4) • Social workers (2)
[ Data collection
[ Data analysis
Research methodology
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Summary
Additional Services
Phase 1: Planning 1. Grant application 2. Planning 3. Formulation of objectives
Phase 2: Implementation
Roll-out of greater NCoP to the community
Phase 3:
Growth
Development
Research
&
Refine
Inte
rven
tions
Additional LO’s &
Skills Development
PROCESS = Appreciative Inquiry
Research Methodology
Discover
Dream
Design
Procedure Centred Forensic evidence
Patient Centred Patient needs
Inte
rven
tions
...DESTINY...
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Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Procedure-‐centred care
Drugs
Follow-up • 3 days • 3 months • 6 months • One year
Discover
Procedure-‐centred care
Dream Design
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year
Discover
Dream
Design
• … I was taken in [emergency unit] immediately…
• …I did not know where to go…we drove around from one
hospital to another…
• …we first went to Delmas [85 km]…we were not helped…then
we phoned our doctor and he suggested we must rather go to
Springs [100 km], since it is the nearest…it was hours before I
was helped [emergency unit]…
Available services
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year
Discover
Design
Dream
• …I thought that because I didn't have a medical fund, that
they (the health care professionals) would not help me…
• …because a lot of people, if they don't have a medical
insurance, immediately think… that there is no hope…I
think everybody must know…there is hope…
Costs
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year
Discover
Design
Dream
• …The sergeant [police officer] was there the whole time…he
arranged everything….he was so kind…very nice…
• …he gave me his jacket…I was cold…he was very helpful…
• …he [police officer]…he helped me…he was friendly…I think he felt
bad…guilty…
• …he [police officer] put the man who raped me in the van [police
van]…I sat next to him [rapist] when we drove to the hospital…it
was a nightmare…this should not happen…it is so unfair…
Police/EMS
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year
Discover
Design
Dream
Incident
• …the room is small…there is no bell…I was scared and wanted somebody
close to me…
• …it is uncomfortable…the door must have a lock…anybody can just walk in…
• …it will be nice if the bathroom is next to the examination room…then you
don’t have to walk through the passage...
Police/EMS
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year
Discover
Design
Dream
• …because the examinaMon on its own is a nightmare…but it
is good…it is important…for jusMce…other woman should
not go through this…
• …[forensic examinaMon] is what needs to be done, and it is a
part of their [health care professionals] work…it is serious…it
is important if I want to go forward…if I want to get over it…
J88
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year Discover
Design
Dream
• …everything [drugs] is for free…I did not know…
• …the nursing sister explained everything to me very nicely…but I told her
that I was going to forget…
• …the sister [nurse] gives you a paper [information pamphlet] which tells
you the times when the tablets should be taken…but then they give you
more tablets than those described on that pamphlet…
• …she [nurse] concentrates on the antiretroviral treatment…but I could not
remember it all…when you should take the other tablets…
• …I could not remember anything…it was so difficult when I went home…
Information • Family/Significant other • Information pamphlet
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year Discover
Design
Dream
• …the nurse came to speak to me and tell me that the results [laboratory
studies]…it was all negative…this naturally made me feel very happy
because on that day you go to get a death sentence…
• …In my mind I saw being listed as HIV-positive…you know that that is what
you think about. ..now this is your life…are you going to test HIV-positive?
• …and all the time I was lying there alone [emergency unit] with these
thoughts…I am going to be HIV-positive…my life is over…I am going to
die…
Laboratory results
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year Discover
Design
Dream
• …They [health care professionals] explained everything, they spoke to my
friend…it helped…I could not remember anything that night…
• …I don't know…my husband did everything...I don't know…
• …It was important to me…to have my mother with me was important, and my
father…
• …and he [friend] was with me in the emergency unit…for follow ups as
well…I did not have to go alone…I would not have made it alone…their
support carried me through the whole process…
Family/Significant other
Incident
Phase 1: Data analysis
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Drugs Follow-up • 3 days • 3 months • 6 months • One year Discover
Design
Dream
• …and then they [health care professionals] told me that whenever I came
back (follow-up in emergency unit], I could just walk through… I didn't need to
ask anyone for anything…but then, on the third day, when I arrived again, I
was not allowed to walk through…the young lady at reception wanted to know
the reason why I was there…then I had to tell the whole story again…
Privacy
Incident
Triage area
Examination Room
History taking
Forensic Examination
Laboratory studies
Procedure-‐centred care
Drugs
Follow-up • 3 days • 3 months • 6 months • One year
Destiny
Incident
Procedure-‐centred care
Awareness campaigns • Available services • ARV costs
Awareness • Transporting female
rape survivors
Examination room • Moved: bigger + shower • Lock
G-file • Admission in the examination room
by nurse versus admin clerk • Follow-up
Laboratory results • As soon as available
Information pamphlet • Family/Significant other
Conclusion
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