Maternal-child health nursing in Indonesia

During winter break of my previous academic year—for those of you in the southern hemisphere, “winter” break at UCLA is in December, not July—I had the amazing opportunity to travel to Indonesia to see, firsthand, the work of front-line maternal health workers. I wrote about my experience as a guest blogger for the Frontline Health Workers’ Coalition. The experience was so much more extensive than what I was able to capture in that blog post, so I am sharing more of my experiences here.

Two things I noticed in Bandung, West Java, Indonesia resonated with me more than anything else: use of text messaging by puskesmas (government clinic) staff and the traffic.

I am a lover of technology and an advocate for use of mobile technology in health care, so I couldn’t have been more pleased to see posters on puskesmas walls with instructions for texting patient-referral information to the local hospital. Clinic staff members said that lack of hospital staff to respond to the SMS gateway (the text messages used to refer patients to hospitals) was a large obstacle for them. Still, use of mobile technology among Indonesian nurses is an important step in health care delivery. I may be a bit biased, as my own research focuses heavily on mobile technology, but that’s OK.

Herianus/iStock/Thinkstock

The other very noticeable thing was the traffic. As a resident of Los Angeles, California, USA, I am used to traffic. My daily activities are scheduled around high traffic times. I decide what time to wake up based on anticipated traffic. I group errands so I don’t have to deal with traffic more often than necessary. I know traffic. However, I had never before experienced the type of traffic I saw in Indonesia. What should be an hour-long drive took us more than three hours. Motorcyclists bobbed in and out of lanes, all the while transporting women and children without helmets. It wasn’t just the public that had to deal with traffic. Ambulances sat in traffic with us. Sirens were on, but many of the cars on the road either wouldn’t move over or had no place to move to. It was no surprise that puskesmas staff members reported transporting patients to hospitals as one of their biggest obstacles.

Nursing practice of midwives in Bandung is very similar to practice of labor and delivery nurses in the United States. Here, we have critical events team training (CETT), where we use simulation to practice handling emergencies. In Bandung, the Expanding Maternal and Neonatal Survival (EMAS) program administers similar training.

EMAS focuses on three areas of maternal health and three areas of neonatal health: eclampsia, postpartum hemorrhage, maternal sepsis, low birth weight, neonatal sepsis, and neonatal asphyxia. Clinic and hospital participants of EMAS are selected based on the number of deliveries and maternal-fetal deaths at each facility. Staff training occurs in the home facility. Staff members are given modules and are responsible for training themselves, based on the notion that, if training occurs away from the home facility, midwives won't know what to do when they go back to their home facilities. I love this teaching philosophy!

As participants in the program, puskesmas staff members are taught what to do during maternal or neonatal emergencies. The program helps increase midwife confidence in caring for high-risk women until the patients can be safely transferred to the hospital. Checklists help in emergencies, and they understand that it is within their scope of practice to administer medications such as antibiotics and magnesium sulfate. Just like American nurses, the Indonesian nurses I met use the Neonatal Resuscitation Program (NRP) model during neonatal emergencies. They also give intramuscular Methergine and intramuscular oxytocin during postpartum hemorrhages. Puskesmas nurses said they were grateful for the increased confidence they have as a result of knowledge provided by the EMAS program.

The EMAS program, which is beginning to bridge the gap between clinics and hospitals, encourages ongoing mentoring and quarterly training. The relationship is mutually beneficial for puskesmas and hospital alike. A memorandum of understanding between clinics and hospitals allows sick patients to be referred to the closest hospital. According to puskesmas staff members, the best outcomes of the program are better clinic management and use of texting to enhance communication between clinics and hospitals. EMAS has strengthened the network among physicians and midwives. Midwives are no longer afraid to call physicians, regardless of the time of day or night, an issue some U.S. nurses continue to struggle with.

The puskesmas nurses told me that their greatest motivation was desire to save the lives of mothers. I could tell by their love for continuing education that this was, indeed, true. I had to travel all the way to the other side of the world to realize that nurses everywhere are one and the same. We may have different cultural practices and slightly different patient-care procedures, but we all cherish good outcomes. Going to Indonesia made me feel part of the global nursing profession. For the first time ever, I felt as though nursing was bigger than what I have known it to be in the United States. Nursing for me is now a global endeavor. Almost a decade after graduating from nursing school, I have a clear understanding of the importance of nursing practice, both inside and outside of my country.

I hope to continue traveling internationally to meet other nurses and gain better understanding of how they practice. There is so much we can learn from each other, so much knowledge and love to share. I am honored to be a member of the Honor Society of Nursing, Sigma Theta Tau International (STTI). When I was inducted into STTI, I had no idea I would someday travel the world meeting nurses and writing about them, an honor I do not take lightly.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Age is just a number

I have a confession to make: I have a slight complex regarding my age. As I enter the last year of my 20s, I have had a lot of time to reflect on my achievements and accomplishments. I must say, I’m proud of myself! I’ve done a lot in the last 28 years. But I have also been discriminated against and discredited because of my age. Unfortunately, the negative comments about my age had a greater effect on me than the positive remarks I have heard.

During the 5 1/2 years I worked in labor and delivery, there was one question I dreaded more than any other—“How old are you?” I recognize that I look much younger than I am—maybe someday I’ll learn to appreciate it—so it’s not a surprise that my patients have a habit of inquiring about my age. Still, something about asking my age makes me believe I am not as trusted a nursing professional as some of my older colleagues.

Some may say I’m overreacting, but I have seen the look in the eyes of women under my care when I tell them my age. I have also heard the change of tone in their voices. Many a night I swallowed my pride, picked my feelings up off the ground and continued to work through my shift, knowing that, solely because of my age, my patient or members of her family were suspicious of my abilities as a labor and delivery nurse.

I’ve also seen the positive side of telling people my age, but honestly, overly congratulatory folks don’t make me feel any better than their negative counterparts. When they hear that I’m 20-something, their eyes light up and they make comments like, “Oh, my goodness, I am so proud of you!” This type of reaction makes me wonder what exactly are people so proud of.

Now, if I mentioned the awards and honors, scholarships and grants, and leadership experience listed on my curriculum vitae, I would expect the shocked reaction. But, is a reaction like this warranted, simply because I became a registered nurse at age 24? Is that really a great accomplishment? When nursing diploma programs were the most highly coveted way to become an RN, 20- and 21-year-olds were graduating with a nursing license. So again, I don’t really understand the excitement about a 20-something-year-old woman who has decided to become a registered nurse.

What I have begun to tell myself, whether the comments regarding my age are positive or negative, is that age is just a number. There are numerous people who did great things at a young age:

• Martin Luther King Jr. received his doctorate degree from Boston University at age 26. He went on to become the father of the civil rights movement.
• Mark Zuckerburg co-founded the Facebook social networking site at age 20. Time magazine named him Person of the Year in 2010.
• At age 25, Lady Gaga was the highest paid celebrity under 30, according to Forbes magazine. She already has three Billboard Music Awards and five Grammy Awards, and she has set many Guinness world records, including the fastest-selling single on iTunes.
• Bill Gates was only 24 years old when he co-founded Microsoft. His company has become one of the world’s most recognizable and its software the most utilized. As a matter of fact, I am using a Microsoft program to compose this article.

As you can see, a person’s age does not have to be a limiting factor. As nurse leaders, we have to move away from the mindset that nurses need to be in the profession 10-plus years before they can make any notable contributions. There are plenty of young nurses who have the experience and drive to move the profession forward. Those of us in Generation X may not accomplish tasks in the same manner as baby boomers, but trust and believe we can get the job done.

Young nurse leaders, don’t allow your colleagues to look down on you because of your age. Seasoned nurse leaders, don’t discredit the wonderful ideas of your younger colleagues, based on their age. And above all else, take hold of your dreams, no matter your age.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

The night hello meant goodbye

It was a night I’ll never forget. It started off like any other night in Labor and Delivery; we were short-staffed and running around like chickens with our heads cut off. I was assigned to work in triage and, considering I love working in triage, didn’t mind the constant flow of incoming patients.

A late-preterm patient, with a sweet disposition, came in complaining of ruptured membranes. She wasn’t scared, wasn’t anxious, just slightly inconvenienced. I introduced myself and began to do all the things a triage nurse does when a new patient is admitted. I had her change into a gown, noted the fluid and attempted to place the fetal monitor and tocodynamometer (the ultrasound device used to record uterine contractions).

I tried for a few minutes to locate fetal heart tones and, when unsuccessful, put a request in to the physician on call to assist me. While waiting for the physician to arrive, I brought the ultrasound machine to the patient’s bedside and tended to other patients.

The on-call physician examined the patient and asked for the assistance of another physician. Any experienced Labor & Delivery nurse understands that, when a physician is using ultrasound to locate fetal heart tones and calls for a second opinion, it’s actually to confirm absence of heart tones. Stopping what I was doing, I walked to the patient’s bedside. The second physician confirmed that there were no heart tones. I called my charge nurse to let her know I would no longer be working in triage, because I wanted to take on the assignment of the patient with the fetal demise.

I began to admit the patient while she was in triage, and she called her family to let them know what was going on. She complained to me that she was leaking a lot. I pulled the sheet back and noticed bright red blood. Leaking small to moderate amounts of blood, which we call bloody show, is a normal sign of labor progression, but this was different. Within seconds, the patient had bled through the Chux pad, down her leg and onto the sheet. It was a little more bleeding than I was comfortable with, but I wasn’t highly concerned.

As I continued to get the woman ready for transfer to a private room, she began to bleed again. This time I was concerned and called the physician, who decided the patient would be taken to the operating room for a Caesarean section. There was no urgency to save the life of the fetus, but the life of the mother was now in question. She would hemorrhage if we didn’t move quickly. The surgery went off without a hitch. The physician confirmed placental abruption as the cause of the bleeding.

I carried the baby over to the warmer and began to wipe her off. She was beautiful! A perfectly formed, beautiful little angel. I wrapped her in a blanket and carried her to the recovery room. The circulating nurse remained in the operating room with the patient while the physicians closed the incision, and the family members came with me. We were not very busy in triage anymore and there were nurses on the unit with no patients, so I decided to take my time and give the best possible care to my patient and her family.

I began postmortem care by doing something I’d never done before to a deceased infant—I gave her a bath, preparing a basin just as I would for any other baby. I washed and dried each part of her body, then her hair. After placing a T-shirt and beanie on her, I let the family sit with her as she lay under the warmer. Later, the mother came into the recovery room to grieve with her family. (There were no other patients in the room, so I allowed the family to come in, without worrying about the one-at-a-time rule.)

As morning drew near and the night shift was ending, I transferred the patient from the recovery room to her room in Labor and Delivery. Once she was settled, I excused myself and walked into the restroom, because I didn’t want her to see me cry. After a few minutes, I was able to pull myself together.

The infant was the most beautiful baby I had ever seen. Although I had taken care of plenty of women with intrauterine fetal demises in the past, this one was different. I was emotionally invested in this family’s unfortunate circumstances. I had cared for the infant as if she were my own living, breathing child. I did not want to believe we all had to say goodbye before we ever said hello.

Walking back to the patient’s room, I told the mother goodbye. I will probably never see her again. She may or may not remember me. But the experience I shared with her will stick with me forever. I have no answers to why such a beautiful baby girl was gone before she ever breathed her first breath, or why this assignment affected me in such a severe manner.

What I do know is that, when I have my own children someday, I will cherish each cry, and each rise and fall of their small chests. Not every parent gets the opportunity to hear their baby scream or feel their baby’s breath on their face. Sometimes, saying hello means saying goodbye.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

I'm going to Disneyland!

After working as a labor and delivery nurse for 2 1/2 years, I decided it was time to head back to school. It wasn’t a hard decision to make; after all, I’d spent the better part of 18 years in an academic environment, and the 2 1/2 years I spent working full time made me long to be back inside a classroom. So, I went to back to school, complaining about how long it was going to take to finish. There were many days of seemingly relentless stress and nights when I burned the candle the whole night through but, before I knew it, I was lining up to walk across the graduation stage. They called my name—“Master of Science in Nursing … Tiffany Monique Montgomery,” I shook the hand of the college president and walked off the stage. Now what?

Before the start of my last year of the MSN program, I began to throw around the idea of going back to school one last time for my PhD. The thought of obtaining a PhD was somewhat of a fairy tale but, once graduation was over, it became an idea that was very real. I began to think about my high school ROP* instructor, who told me that each level of my educational process would be a little easier than the level before.

When I was an anxious high school senior preparing for graduation and not knowing what life as a college student would hold, she told me my high school diploma was the most taxing diploma I would ever earn. At the time, I thought she was nuts, but now, as I looked back, I understood what she meant. Each time I graduated and decided to return to school, I was studying something I wanted to study—something I was interested in, something I got excited about, something that made me want more knowledge. She was right; each diploma was a little easier to obtain than the one before, not because the coursework required less effort, but because my hunger for knowledge was a little stronger. After reflecting on the words of my ROP instructor, I decided I would allow my education to take me as far as I could go. I was going to earn my PhD!

I began the application process the same day I attended the PhD program orientation at the University of California, Los Angeles (UCLA). When I walked into the orientation, UCLA was one of two universities I was considering to pursue my PhD. By the time I left, I had decided it was the only program I would apply to and, if I did not get in on my first try, I would continue applying until the university accepted me. That evening, I created my profile on UCLA’s online application website. I completed as much of the form as I could and began piecing my statement of purpose together. Little did I know at that time, I would be logging on to the site multiple times each week, and my statement of purpose would be revised almost every other day.

I learned during the program orientation that, after applying to the PhD program, meeting with current professors to discuss potential research areas is a good place to start, so I scheduled meetings with two nursing professors. Before those meetings, I thought I wanted to study nursing education, but they inspired me to study an area of nursing that I loved and not simply list an interesting research question in my statement of purpose.

It didn’t take long to acknowledge the area of labor and delivery I loved most—working with teenage patients. Don’t get me wrong, I don’t like the fact they are pregnant, but caring for a pregnant teen brings out a sense of compassion and motherly protectiveness that I never felt when caring for adult women. I realized my desire, more than anything else, is to prevent teenage girls from having to face the harsh realities of motherhood. This is when my research focus changed from issues in the labor and delivery triage unit to teen-pregnancy prevention.

I wrote and rewrote, edited and revised my statement of purpose more times than I can count. Fifty revisions is probably on the conservative side. I changed the order of some paragraphs and completely deleted others. The part of writing the statement that I found most difficult was discussing my personal achievements. I understood that, because the PhD program does not include an interview as part of the application process, I had to “sell myself” on paper. But no one has a more difficult time than me when it comes to boasting of my accomplishments. While I enjoy keeping my friends and family abreast of my latest professional endeavors, I am not one to brag. I reviewed an early version of my statement of purpose with one nursing professor who told me I needed to do a better job of marketing myself. So, I went back to the drawing board and, as difficult as it was, I boasted of some of the wonderful successes I have experienced.

After working on my application for about two months, I finally pressed the Submit button. All of the transcripts had been mailed and letters of recommendation requested. Now, all I had to do was to wait … and wait … and wait. Waiting was, by far, the most challenging part of the entire application process. Once, during the waiting period, my mother asked me, “What are you going to do when you get in?” I remembered the old commercials from my childhood featuring Super Bowl champions, and I replied, “I’m going to Disneyland!”

Waiting to hear back from the school seemed to take forever, but that fateful day finally came. When I learned that I had been accepted to the program, I was overjoyed. I can’t quite put into words the way I felt. My dreams were coming true. Not long after word of my acceptance came, I was informed that I had also been awarded a fellowship. This was news I could not prepare for; for about a week, I felt like I was in a dream. Every time I told someone my good news, I smiled uncontrollably and wanted to pinch myself to make sure I wasn’t dreaming. I’m still in shock and in awe that I am entering a nursing PhD program in a few short months, and my tuition is already paid for.

When I was a high school senior, you couldn’t have paid me to believe I would someday be accepted into a PhD program. Me? No, not me! I’m the young woman from a broken home in Long Beach, California, who almost didn’t go to college because my mother couldn’t afford it. I wasn’t poised to become a nurse researcher then, but here I am, 11 years after my high school graduation, remembering the wise words of my high school ROP instructor and looking forward to all of the struggles and triumphs this PhD program will bring.

Disneyland, here I come!

*Regional Occupational Program (ROP) is a career-training program for high school students.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.