journey towards practice development for rape survivors

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

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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…


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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


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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


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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


Laboratory studies


Drugs


Discover


Dream Design

Incident

Phase 1: Data analysis

Triage area

Examination Room

History taking


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


Triage area

Examination Room

History taking


Laboratory studies


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


Triage area

Examination Room

History taking


Laboratory studies


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


Triage area

Examination Room

History taking


Laboratory studies


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


Triage area

Examination Room

History taking


Laboratory studies


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


Triage area

Examination Room

History taking


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


Triage area

Examination Room

History taking


Laboratory studies


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


Triage area

Examination Room

History taking


Laboratory studies


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


Triage area

Examination Room

History taking


Laboratory studies


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


Laboratory studies


Drugs


Destiny

Incident


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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journey towards practice development for rape survivors

Education