Perspectives from a Community Health Nurse

1
Perspectives from a Community Health Nurse

• Paula Bailey, BScN
• Health Canada, First Nations Inuit Health

2
Initial Activities

• Received call from TB Control case identified
• Stop all other non-urgent community programs
• Arrange for home visit to client CHR
  accompanied (able to assist in locating clients
  residence)
• Client was at home - Advise of Diagnosis
• Call local Ambulance, as there were no other
  immediate options for transportation. Client to
  be admitted to University of Alberta 5C3
• Mask provided (N95)
• Ambulance had to take client to nearest hospital
  first before transfer to U of A
• (Client admitted 17 days)
• Call for additional support/assistance at
  community level (FNIH TBC, other CHNs) due to
  staff shortage

3
Community Profile

• First Nations, average on reserve population is
  1400
• Transient population to other surrounding
  cities/communities
• Health Determinants affecting the community
• unemployment
• overcrowded living conditions average bungalow
  style home has upper limits of 8-20 people, often
  several children
• addictions
• poor high school completion rate
• high birth rate (young population)
• lack of access to services
• transportation barriers - gravel roads affect
  road conditions, few people have their own
  vehicles
• few home phones
• Nearest hospital approx. 25 km away
• 1.5 full time nurses presently working in
  community

4
Identifying Contacts

• Lists compiled over a period of about 2 weeks
• Assistance from cases family, self-identified
  contacts, CHR, TBC
• Initially 16 household contacts identified
  (clients current residence)
• Client also identified time spent in other
  households, which increased total household
  contacts to 33
• 22 Daycare children and 11 staff - close non
  household contacts
• 26 Classmates at school casual medium risk
• 33 Non household - casual medium risk

5
Identifying Contacts

• 11 emergency room contacts also identified
  casual medium risk (followed up by Edmonton TB
  clinic)
• Contact list updated and submitted to TBC
  regularly
• Chart reviews completed
• 145 total contacts identified

6
Recommendations from TBC

• Symptoms inquiries
• TSTs for those eligible
• 3 consecutive sputums for anyone symptomatic
• Previous/current positive TSTs referred for CXR,
  bloodwork, sputums (forms filled out given to
  contacts to complete at nearest lab)
• Children under 5 weight, accompanying letter to
  parents also indicating need for Ax by MD, repeat
  TST 8-12 weeks, offer for prophylaxis medication

7
Initial Challenges

• Contacts not having a phone, not home, out of
  community, no one knows where they are
• Multiple home visits safety concerns (dogs,
  substance abuse issues, road conditions)
• Addressing community concerns regarding
  transmission
• Community concerns and reactions to fear
• Kids of contact case being teased in school,
  parent chose to remove children from school
• Sifting through other possible contacts
• Lack of transportation
• Low priority, lack of interest from contacts to
  complete recommendations in a timely manner
• Parents reluctant to start treatment for their
  children under 5 yrs
• Not everyone had a family physician
• Apprehensive in providing sputums

8
LTBI Medication

• 29 contacts recommended LTBI, with positive TSTs
• 21 accepted
• 18 completed
• Including 7 children

9
Information Distribution Communication
Strategies

• Communication to Health Director (who
  communicated to Chief Council), health staff
  inservice, updates
• Teaching on the spot to contacts
• Info. session at daycare for parents staff
• Info. session to school staff
• Ongoing info. to contacts, resources provided
• TB Display at Health Centre, TB pamphlets,
  newsletter

10
DOT Worker

• Everyone on TB medication is required to be
  monitored by DOT
• Community member trained to perform this duty,
  also assisted by CHR, Home Care, CHN
• Difficult to staff - lack of interest /
  misunderstanding of position
• Reports any side effects/concerns to CHN
• Completed symptom inquiries, collected sputums
• Provided transportation to lab for required
  bloodwork, CXR as per TBC recommendations
• Meds prepared by RN in advance of delivery
  dosettes, individual doses
• Arrangements had to be made if CHN not available
  FNIH TB nurse came out

11
DOT Challenges

• Finding the client may have to make several
  attempts at different times and homes to find
• Side effects of medications
• Adults not feeling well (upset stomach)
• Did not like aftertaste
• Children spitting up, crying, hiding, biting,
  multiple tries/ CHN having to remix meds
• Did not like taste
• Crushing into juice, pudding, peanut butter
  sandwiches, frozen pops Limited by formulations
  of meds.
• Parents had hands off attitude towards med
  delivery

12
Incentives

• Provided juice/water snack with every dose
  (granola bars, cheese/crackers, pudding)
• Kids - toy, candy given with every dose,
• movie passes (didnt like because theatre too
  far)
• 10 Wal-Mart gift cards every 2 months
• Adults - 25 Wal-mart gift cards every 2 months

13
Other Considerations

• Self identified contacts initially cooperative,
  but then didnt follow through with
  recommendations
• The history of First Nations and TB has led to
  general negative feelings around TB treatment
  (ie sanitoriums, removal of children/family
  members, forced medications)
• CHN, CHR dropped sputums off at lab when
  necessary

14
Summary of Principles

• Respect cultures and values of community
• Develop rapport trust to build relationships
• Information available through family/friend ties
  ie client change of location/residence
• Provide ongoing support and education
• Work within the clients realities dont give up
  there will be challenges
• Recognize differences in priorities
• Accommodate needs transportation, place of
  residence, repeat attempts
• Have awareness of what's happening in the
  community
• Ultimate goal informed choice, health
  promotion, prevent future cases