Building capacity from the ground up

An Australian provider shares their experiences of working to improve the health outcomes of Asia’s youngest nation. Linda Belardi reports.

Perth-based St John of God Health Care has spent the last two years working in Dili’s national hospital, Hospital Nacional Guido Valadares (HNGV), developing the capacity of East Timorese nurses to deliver a higher standard of patient care.

The nursing development program run in partnership with the East Timorese government is still in its early stages but it has already achieved some important milestones. A recent independent evaluation of the mentoring and training project said it has delivered not only tangible improvements to hospital and nursing practices, but also generated a genuine sense of pride amongst local staff and management.

Development expert, Dr Elizabeth Reid, who conducted the evaluation, said the program is appreciated by the Timorese at all levels and has earned strong support for the project to be continued and expanded.

“Few capacity building efforts in Timor-Leste create such a sense of pride in achievement, of self-esteem and engagement, particularly during their establishment phase. The National Nursing Development Program has achieved this,” Reid wrote in her 2012 review of the project’s first year in operation.

Anthea Ramos, Group Manager for International Health with St John of God Health Care says earning the trust of the East Timorese staff and building strong relationships has been critical to the program’s success.

“Understanding the local culture, how relationships are maintained, and the level of expertise already on the ground have been important challenges for the trailblazing team,” she says. “This is especially important in East Timor because it is a relationship-based society.”

The project has also been recognised for setting up a sustainable foundation by deploying expatriate nurses on a permanent 2-year contract instead of on a fly-in, fly-out basis. The Dili-based nurses are also supported to learn Tetun, the local language.

The program at the Guido Valadares National Hospital targets areas of highest morbidity and mortality and currently includes a team of 9 expatriate nurses deployed to the specialisations of paediatrics, emergency, intensive care, neonatology and quality control.

When the Ministry of Health first approached St John for support in 2008, Dili’s national hospital was functioning with only a small team of nursing staff and had limited opportunity to grow its workforce. Formal nursing training has only recently resumed in the new nation and the first cohort of new graduates is just about to enter the workforce.

ICU nurse specialist Rachel Smith had been volunteering with a Dili-based NGO for malnourished children before she joined the St John of God team last year. She agrees that the key to capacity building is developing strong partnerships so that the local nurses can be empowered to lead the change.

Smith, who works in the hospital’s 6-bed ICU unit, says mentoring is about leading by example. “It’s about showing, not doing. I’m not the expert in their environment. We are there to work in partnership alongside the nurses to improve processes and standards of practice. “Building relationships and developing a strong foundation for the nurses to want to work with you is your first and continuing role,” she says.

“But it is the nature of development work that progress is not always linear. You might take two steps forward and one step back.”

The challenge is also to avoid lecturing but rather to facilitate discussion, role modelling and a sense of agency among the local staff.

On the ICU ward Smith says the most common cases are motor vehicle accidents and head injuries, as well as stroke and cardiac patients. But a lack of supplies and equipment makes the experience of nursing in this environment very challenging.

Many patients also come to the national hospital in the latter stages of their illness. “The hospital setting has a bit of a stigma attached to it,” she says. “For many local Timorese, it’s seen as the place where people go to die, and so people don’t come in until they absolutely have to. We see the sickest patients and often people are sent here for palliative care, which is why ICU has such a high mortality rate. As a team, we have also to adapt our attitudes for the environment that we are working in. What you’ll find in East Timor is that the society has a very different attitude to death.

Because they are so used to seeing death - not only during the Indonesian occupation but because of the nation’s high rates of maternal and infant mortality - the society has a very different attitude to what mine was when I first arrived.”

Due to nation’s young population - 50 per cent are under the age of 20 - paediatrics is also a significant and growing area of need.

Often the corridor of the two paediatric wards is filled with patients, especially during the wet season when a higher number of Dengue and malaria cases are common. The unit also sees a significant amount of malnutrition and one of the wards is dedicated solely to malnourished children, says Smith.

Despite these challenges, Smith says she has identified a noticeable change in the confidence of staff, which is particularly evident in the dramatic reduction in her on-call and out-of-hours support to the local nurses.

Amongst the East Timorese nurses there is a mixture of skill level and education, but poor motivation due to low wages is a significant socio-political issue which can affect the change management process, she says.

Throughout the hospital, communication and documentation are also problems as many languages are spoken. Smith says there is a diverse mix of Cuban, Portuguese, Chinese and Indonesian doctors, which creates a significant risk of error. “The nurses often have to chase up doctors because they don’t understand the doctor’s notes,” she says.

Despite the slow pace of change that characterises aid and development work, Smith likes to remind her colleagues that irrespective of whether it is a developed or developing health system, change is always difficult. “Generally people are resistant to change. It is always a very slow process but in East Timor it is more emphasised because of the history and the lack of education.”

Once improved practices have been embedded and shown to improve patient outcomes in Dili’s national hospital, a national roll out to East Timor’s five district hospitals will be explored.

Facilitated training in Australia

As part of the nursing development program, the East Timorese nurses also have the opportunity to undertake intensive training in Australian hospitals. On a recent trip to Perth and Darwin, Smith facilitated the training of three East Timorese nurses from the ICU ward to develop their skills in ventilation, patient assessment, documentation and communication.

The training placements encourage the nurses to learn a wide range of new skills which they can then share on the wards. “The goal is to give them exposure to a different culture of nursing,” says Smith. “Not everything that works in Australia will work in East Timor, but the nurses can reflect on how the relevant training could be adapted to their local context. Once they return, they can make some recommendations for change.”

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