Sandholm Refugee Camp

17 July 2007, Tuesday


Denmark’s leading political newspaper Politiken reports, on January 6th, 2007, that 11 local priests at Hillerød Kommune, together with a couple of hundred supporters, are protesting against Danish asylum rules that would force hundreds of Iraqi Christians to go back to their own war-torn country. Danish People's Party's chairman, Pia Kjærsgaard, has earlier dismissed every thought about rescuing Iraqi asylum-seekers:

"I think it’s only fair, face to face with all parties
concerned now, to prove that 583 turned-away Iraqis,
under no circumstances, get permission to stay in Denmark.
Law is law, and law is to be held. Therefore they are to be
sent home", writes Pia Kjærsgaard.
(Prasz and Dahlager, 2007)

Those Iraqis have been staying in the Sandholm Refugee Camp near Hillerød. The situation described here tells the tense political atmosphere around the facility. Today, I am going to visit the Sandholm Refugee Camp. Last Sunday, I have attended a church, International Church of Copenhagen, one of the few English-speaking services close to the Deaconess Foundation. I had found the church’s website and knew the pastor there has been shuttling the Iraqi Christians to his church on some Sunday afternoons from the Sandholm camp. After the service, I waited for a while for the pastor to greet his congregants and introduced myself. He is an American Lutheran pastor from Carolina. His own website tells that he has visited Sandholm with his children. I told him about my Community clinical rotation in Denmark and mentioned that I would visit Sandholm soon. He was glad to find out that UVa Nursing School has sent a student to see Sandholm all the way from the States. I got more excited.

Last night again, I fell a sleep after 2, worrying about not being able to wake up on time for the metro and train trip to Sandholm. I barely wake up in the morning just to wash and brush. It takes about one and half hour with some room to get to the train station Allerød. I am taking the bike to ride to the metro and realize that I forget the mobile phone. In case Ms. S calls me at the train station, I would need it. I leave the bike in the elevator to get the phone and when I return, the elevator would not come back. I go down to the basement and wait. No elevator. After wasting good 20 minutes, I leave the bike there and run to the metro. At the Allerød train station at 9:04, Ms. S was waiting for me. I did not have to go back to get my mobile phone. I am the only male who has gotten out there, she says.


Google Earth version of the Sandholm Camp. The closed camp is the right half with the soccer field.













She is a good-looking middle-aged lady who drives a new Toyota. There is a kind of toughness in her weathered face. She works at the close camp portion of the Sandholm Refugee Camp. She started to work here in 1994 then took years off to take care of her children, and came back two years ago. She first applied to work here because of her interest in the refugees and previous experience in counseling. The open camp is right next to the closed camp. Actually they are at one site and used to be one Army barracks. Now, the close camp is run by the Justice Department, the open camp the Red Cross, and tall fences divide the two with barbed wire on the top. No one is allowed to the close camp without pre-approval and appointment. I am probably the first American nursing student visiting the closed camp. Not even one Danish nursing student has visited here to protect the inmates’ identity. Yes, they are called inmates. They are probable political refugees seeking asylum in Denmark but until proven, they are inmates. When their cases on review show some hope and they are about to go out to society, the inmates in the closed camp are moved to the open camp. Until then all inmates in the closed camp are treated the same as prisoners in the Danish prison system, except they are not criminals and have a bit more freedom to move about. They are not allowed to leave the closed camp. Refugees in the open camp are free to leave the camp and come back. All the IDs and documents are not shared between the two camps. They are separate organizations. Many inmates are sent back to their countries from the closed camp. When the clinic at the open camp needs the nursing charts from the closed camp, Ms. S hand-carries them to the open camp. It used to be a walking trip. Now, she drives around the fence. I asked her about the Iraqi refugees mentioned the above. She did not know about them. They might be in the open camp because nobody is allowed to go anywhere from the closed camp.



After driving about 10 minutes, we pass the open camp first. Most buildings are one-story simple structures. She drives to the corner of the complex and turns right twice. Then, I see an enormous gate as I have seen in the movie Jurassic Park. There is a camera looking at us. It opens itself. Then there is a pathway leading to another gate. Tall fences block both sides of the pathway. At the second gate, there is an interphone to talk to. Ms. S waves at the camera and the gate opens. Once inside the main building, she opens a key box and replaces her key bundle with the camp’s key bundle. Also, she takes a wireless walkie-talkie and an emergency beeper. I get a beeper myself. It is in case of emergency attack by inmates. She says it has never happened and do not push the red button. I carefully drop it in my trouser pocket. There are tall well-built guards and staff. I am introduced to each of them. Ms. S leads me into the observation room. One wall is filled with more than two-dozen monitors. The guard, sitting in front of the computer, says, “When you move, we can see.” The cameras used to monitor up to 150 inmates and now there are about 50 in the closed camp including women, who stay in the separate building. Nursing staff used to be three total but now there are two who take care of the whole camp inmates. Another nurse is on vacation now so Ms. S is responsible for all of them today. Ms. S picks up a bundle of medicine boxes from the main office and leads me to her clinic. A general practitioner is assigned to the closed camp. He visits the camp two or three times a week. He was here last night to check one inmate and ordered an endoscopy lab to see his stomach for ulcer. Every Monday, inmates go out to a hospital that is connected to the Copenhagen Prison for non-emergency labs, X-ray, and emergency dental visits. Others go to local hospitals depending on which body system they have troubles with. When hunger strikes among inmates happened, they were left as they were and not moved to the hospital. Unless they are mentally sick, it is their choice not to eat, Ms. S says. There is no force-feeding in the policy and they quickly eat again after they demonstrate their anger and frustration. This is totally different type of nursing care.

The clinic looks similar to any doctor’s clinic. The door is locked behind me as I enter the room. She says all doors in the camp are kept locked all the time. The clinic has a desk with a couple of chairs for inmates to sit in the front. There is a computer with a screen saver that says “Kriminalforsorgen Sandholmlejren”, literally meaning Sandholm camp for Criminal-welfare, but it stands for Danish Prison and Probation Service at Sandholm Camp. There is a bed on the side. Inmates sign up if they have medical problems or want to see the nursing staff. Ms. S says one of the main routines for her is to listen to inmates. There is also a social worker who helps inmates and listens to their problems. Priests come in for service once a week and for personal talks. Psych consult is provided since post-traumatic stress disorder is expected if the inmates truly have endured torture and suffering. For a new inmate, a simple exam is given to check past medical history, vaccination records, and chief complaints. Preventive tetanus shots are usually given to the incoming asylum seekers. There are brochures called “Guidelines for asylum seekers held in detention” in Danish, English, Turkish, Somali, Servian, Russian, Arabian, etc. It summarizes the camp rules and detainees’ rights. In the closed camp, inmates can work in a workshop to earn money. This is the same as the other Danish prison system. There is no work available in the open camp. Every Wednesday they get allowance for their work and they line up to buy sodas, cigarettes, etc. in the camp mini shop. There are exercise room, laundry room, and library for inmates. Also there is a school with teachers for Danish, social education, and sport. House rules, disciplinary measures, and grievances are explained as practical information. Ms. S says that there is a solitary confinement (“rubber room”) with beds that cannot harm inmates. Sometimes some inmates choose solitary confinement by themselves. Whether they are extremely depressed or just want to avoid the crowd in the camp, is not sure. Ms. S has lead me to one such guy during the day but he seemed to be calm and with his self. When an inmate is confined there as a disciplinary measure by hurting themselves, he or she is checked every 15 minutes for safety. The room has a window with metal pipes and looks scary. If inmates hurt others, they go to police and real prison.


Nurses at Sandholm check and fill medication prescription in the small pill boxes every week. There are about 15 inmates who get regular meds. There are many medication drawers and it is sometimes difficult to find particular drugs. The pill boxes are placed in the main guard office and inmates cannot keep them. They should ask the guards every time they have to take the meds. Ms. S takes me to male inmates’ cells for a tour. There is one guy she has to find. He came in yesterday and needs a diabetic medicine today. His bag with meds and blood sugar measuring tools is in possession with the guards. The building has six wings and each wing holds about 10 inmates. One wing is not used currently. There is a locked prison door to each wing. Inside the wing, inmates are free to roam around between cells to talk to their friends, play ping pong in an exercise room, and go out to inner courtyard to smoke. There are graffiti everywhere on the wall in the wing’s hallway, accusing “Danish racists”. Cells themselves are about college dorm sizes with two beds in some rooms. Most cells are quite messy. Ms. S says there are cleaning tools available but they rarely clean up their rooms. One room per each wing though is usually kept neat and clean. Inmates swap their cells. It seems like there is an invisible rule how they occupy certain cells. For truly traumatized asylum seekers, the condition in the wing does not look peaceful at all. Hallway is narrow and cells are dirty. I would not be able to stay there more than an afternoon. Ms. S checks the sign up sheets. A few people have signed up. She puts a new form there with today’s date. She wants to have the nursing session in the clinic most of the time to give the inmates some time-out away from the cells. They diabetic guy is not in his room. She checks other rooms and finally finds him. He is escorted back to her clinic. She checks his blood sugar and it is 132. Not too bad. He gets a diabetic medicine. While she looks for the med, he talks to me how he ended up here. He is from India and requested asylum in Norway. He was arrested in Denmark with his wife and kids. He is brought here while his wife and kids stay outside. They are to be transferred to Norwegian authority soon. Ms. S says some asylum seekers want to shop the country they want to live in and they move around among European countries. But the rule is that they have to seek asylum in the first European country they land from their own country. Sometimes inmates are brought back to Germany where they have initially requested asylum.

Ms. S takes me this time to women’s facility. There are 10 of them currently in a separate building. Children are not allowed to be in the Sandholm closed camp. I meet two guards in the guard office, one female another male. The male guard makes coffee for Ms. S and me. He looks very nice and kind. They start small talks. He was on vacation recently scuba-diving in a South Asian island. Ms. S and I go in to the women’s quarter after the locked prison door. It is more spacious and clean than men’s quarter. There is an open space with a table. Out in the courtyard, a few pieces of laundry are hung on lines to dry. Someone wrote words on the bulletin board: “There is a hope and there is life outside. Do not lose hope. Trust in the Lord.” Ms. S checks in two female inmates. One has bladder problem and another has urine sample to check UTI. One lady locked herself in so Ms. S has to unlock the door. The lady was just slow to answer the knock on the door. She is from Uganda. She looks neat and is soft-spoken. Ms. S greets some other ladies and we get out from the quarter. Many inmates have psychiatric problems. I do not know the statistics how many inmates have post-traumatic stress disorder. But anybody would say that for those who have been traumatized, a forced confinement itself is part of the problems for these inmates.

Ms. S has to take a medical/nursing chart to the Red Cross open camp so I have chance to see the open camp. There is no guard at the gate. The gate office has a female worker in plain clothes and she greets her. She says I am a nursing student from Virginia. It takes a while to find the building that has the clinic because they are painting the buildings and the building numbers have been taken off. My schedule to visit the open camp tomorrow is cancelled because the clinic staff is on vacation. People are free to walk around the campus and I see many people, Middle Eastern, Africans, even Chinese. Ms. S greets several young Chinese people who pass by. Their faces shine up when they see Ms. S. The nurses in Sandholm closed camp is in unique situation in that they are the ones who decide if inmates would need further assessment or treatment. They are probably the closest person to inmates and know them individually. I could see the emotional toll they would experience when things happen. I asked Ms. S during lunch if she saw any blood shed. She says that one inmate cut his wrist and was brought to the Copenhagen prison hospital. He survived. I asked again if she had any stress from her work. She says she gets tough after a while.

After lunch, she showed me the soccer field, indoor gym with basketball court, and other rooms that used to be used when the inmates numbered more than 150. Now they are closed and locked, even Ms. S could not open them. She goes another round to the male quarter to talk to some inmates. One guy has asked her a couple of times to see him quickly. She sees him in his cell and introduces me to him. He complains of his tendency to get upset and he says he does not know when he would act out his anger. Ms. S tells him to back off from any stimulant and try to calm himself. He asks for psychiatrist consultation and she agrees that she would find the time for appointment. Later, she says that he used to take anti-depressants and now he asks for higher dose in his relaxant. She says that Benzodiazepines are used cautiously because inmates become addicted to it. We also go back to the women’s quarter to tell one lady that her urine dip stick result is negative for UTI. Another lady from Uganda says she has just been notified that she would go back to Uganda tomorrow.

Regardless of their past, the life of Sandholm’s inmates is tough. Previous medical problems that they bring with them including PTSD, problems that confinement itself causes, and hopelessness from their undefined future, all influence their mental and somatic condition. Danes complain that the inmates, when they get out to Danish society, receive more benefits than other Danes and still do not work as much as they do. Cultural integration of foreigners is one of the most sensitive issues in Denmark today. It is the Danish society that will decide the future of asylum seekers. Until then the nursing care in the Sandholm closed camp is the most crucial service they can have as inmates for their survival. I returned to my temporary home at the Deaconess Foundation in the late afternoon with heavy heart. I realize that today’s experience will be with me for a long time.

Kofoed School

Kofoed School is a place to nurture the socio-economic outcasts, to help them self-help, and to build their self-respect.




One of the many workshops at Kofoed School is the Greenlanders workshop.

Preventive Home Visits

Here is the brief history of Danish Preventive home visits:

• 1937 Health nurses visits home after childbirth
• 1950 the Danish Medical Association discussed whether functional decline was preventable with earlier interventions
  
• 1960-1970 District nurses 'knock on doors' in a local authority of Copenhagen
• 1980 the Roedovre project and the Commission on Older People suggest that preventive care be prioritised
• 1996 the Danish Act on Preventive Home Visits implemented to cover all +80 year old
• 1998 all 75+ covered by preventive visits
• 2002 Systematic scientific analyses of 18 controlled trials define criteria of effective preventive home visits
• 2005 Amendment of the 1996 Act reaffirms preventive home visits, but now more targeted to persons without need of personal help
  
• 2006 GP contract includes preventive home visits to frail older people
  

These are some pictures of Home Health Nurses on their bikes.


Nuns used to visit homes in earlier days.















A Home Health Nurse in Summer 2007. Social and Health care Helpers also ride bikes to visit clients.


















Home Health Nurses take one of these red cars from the nearby fire station for the evening home visits. Parking is a lot easier in the evening.

Home Health Nursing

11 July 2007, Wednesday








(Entrance into the Frederiksberg Kommunes Hjemmepleje, Home Care)


I could not sleep well last night with fear of not being able to get up early enough to meet Jette at 7:30, because I did not bring an alarm clock. I finally went to sleep after 2 a.m. but was able to get up and bring down the bicycle to go to the Home Health Agency. It was a short walk from the Nursing school to the agency. We met Trine, a veteran home health nurse, at the agency. She is very lively and energetic person. She had her ADN education in the States and lived there with her American husband so she speaks fluent English. Her husband is the first year graduate of the DIS (Danish International Study Program) and they met while he was studying here. Lucky guy, I thought. Trine and I will be spending the next two days on bikes maneuvering streets of Frederiksberg to visit people’s homes. This Home Health Agency is the only such kind, in the Frederiksberg municipality, that takes care of about 2,000 elderly residents. In Denmark, citizens older than seventy years old get two preventive health visits a year. In Frederiksberg, home health nurses fulfill this health policy. Some municipalities use general physicians to do this checkup in their clinics not people’s homes. Home health nurses play a tremendous role in post-hospital care of medical and surgical patients. It reduces the hospital stay of patients and helps cut down the hospital portion of the health care cost. Other main target populations for the home health care are the elderly with chronic diseases and dying patients at home. Nurses in home health nursing area enjoy their independence and interaction with clients in their home greatly. Trine has worked in the hospital only in the States. Once in Denmark, she took some courses to acquire Danish nursing license and since then only worked in the home health care because she loves working in the community. There is another kind of community nurse called, Health Nurse, who covers citizens from birth to school ages. They do visit people’s homes to check and weigh infants and to help mothers to raise their children. They also work in schools to promote good health. Health Nurses have their own center from which they organize and originate the pediatric nursing care. Trine says that WHO wants to expand the role of nurses and Danes would want Health Nurses to cover citizens of all ages. It would be comparable to Family Nurse Practitioner in the States without the prescription privileges. Hopefully it becomes a reality soon in Denmark for nurses’ sake. For Trine, she would retire before it would be adopted in the educational system.

It's cloudy, windy, and a bit chilly. The rain starts to drizzle. It is still early morning hour of 8:30. Trine and I hop on our bikes and venture out to the busy streets of Frederiksberg. As soon as we get to the first traffic light to make a right turn, she tells me of her history of being ticketed twice by passing the red light there. She was a bit late for her morning home visit and told the police officer about it. But he already knew home health nurses turning on red lights there and was adamant that she should pay 500 Kr ($100). I have never heard of bikers getting ticketed but this is Denmark. Is this maybe another evidence of Danish inflexibility? Trine rides fast and talks at the same time as she rides her bike. My butt starts to get wet and I try to listen to what she is saying. It is quite a joy ride. I slow down to prepare for the right turn as Trine gives me the hand sign, and immediately I get shouted by a biker behind me for not giving a hand sign. OK, I get it. Next time I will do it.

Our first client, Trine insists calling them clients not patients, is an elderly woman who has been discharged from the hospital yesterday. She had been admitted with pneumonia and still has some secretion from both lungs. She also has hypertension, glaucoma that makes her almost blind, osteoporosis, constipation, and dry irritating vaginal wall. Trine’s work today is to fill up her medicine bins and apply the eye ointment. The drug bottles and boxes fill up a big basket randomly and it is tricky to find all the meds, almost dozen of them. Some medicine runs out first and either client’s family or social/health helper should go out and buy the refills. This lady takes a lot of pills in the morning, more than 10, and the pills fill up the small morning bins quickly. It is easiest but takes the most time to fill up the med bins. Nurses need to cross-check each bin, by going through the day of the week, from Monday to Sunday. It is confusing to me because Danes use the comma as decimal point. Also one needs to check if the unit is mg or number of pills. After Trine applies glaucoma ointment on her left eye, we are on to the next patient.

It is still raining outside and chilly. We meet a friendly gentleman who is an insulin-dependent diabetic. He has arthritis in his hands and cannot use the insulin pen to inject himself. He sits down on his armchair and starts talking. Trine introduces me to him as a nursing student from Virginia. It is interesting they do not use the country name, the U.S. or America. They use the State name, either Virginia or Tennessee. Many Danes love Jazz and in early July multiple sites in and around Copenhagen have Jazz concerts everyday. Somebody said NATO has something to do with the US-Denmark relationship. He talks about American politics. He does not like the current administration but is very much fond of Hillary. He says she has written many more books than Bill has. He hopes she gets elected. Trine prepares the insulin pen and gives him a SQ shot on his abdomen. It is the only shot for the day, a mixture of short acting and regular. I asked Trine if he gets another shot in the evening and she said no. It is a problem for him that he does not want to get the evening insulin shot. He is afraid of being hypoglycemic in the morning that he might not wake up. His father and his brother were also diabetic and he grew up watching them suffer. Trine suspects that he and his General Physician (GP) might have some kind of pact and his GP does not order the evening insulin. It bothers Trine a lot because she knows his GP would retire soon and does not really care. He was encouraged to go to the Endocrinologist or diabetes care team but refused. She worries that, in the long run, his organ would be damaged unless his blood sugar is controlled. His flat already smells like urine. She has checked his morning blood sugar level several times and it was always high. It is client’s autonomy and needs to be respected. What would American nurses do in this kind of case, I wonder. Another interesting thing I have observed was nurses here do not use alcohol swab to clean the injection site. I asked Trine about it and she said it was to prevent the drying of skin. She said hospital nurses do use the swab. Later, from a literature search, I found that recently using an alcohol swab at home, here they say ‘spirit’ rather than alcohol, was also recommended.

Next stop is for a right great toe amputee from his diabetes. Trine needs to check the dressing and replace it. Wound care is one of the main nursing care duties for home health nurses. There is a wound care specialist nurse as well as an outpatient wound care clinic in the home health agency. Trine cleans up the wound site with gauze soaked with lukewarm water. She says they have to use very hot water and mix it with cold water to prevent germs from the old pipes in the building. Home health nurses do not carry sterile normal saline for wound care. He twitches a bit when she touches a spot. He shows Trine a doctor’s note that says he needs more months to stay away from his job. He was expecting to go back to his work but now he needs to get the load off his right foot for many more weeks. I mention an antique gun in his dining room and he says that he is a hunter. A vertical cabinet on the corner of the room has more shot guns, he says. I ask him how he is coping with the disability like this and he points a deck of old chest drawers. He bought some old furniture to restore them at home. Trine says he is noncompliant and walks to stores and parks. He also refuses to wear the Care-cast boot at home. He can stay home for up to 6 months while his toe heals. He still gets the full salary and the health care is free. Hopefully he enjoys his time-off and goes back to work before the weather gets too cold.

We are about half done for today. Home health nurses visit 10 to 15 clients during the shift. Similar to nursing home staff schedules, there are three shifts a day, morning, evening, and night. Evening and night nurses drive small red cars owned by the municipal government. They are parked across the Agency in the local fire department parking lot. Trine gets only 5 clients when she precepts nursing students. Her manager complains because of that. This home health agency exclusively accepts nursing students from Diakonissestiftelsen. I could read the pride from her voice that the agency produces excellent nurses through their training program. Nursing students are trained for 8 weeks, from Monday to Thursday. Trine mentions that in the early weeks, the students do not know how to interact with clients. Some students excuse themselves, saying some clients refuse their visits. But near the end of 8 weeks, they start to learn the fun side of the home health nursing. There is a nursing student working during the summer as an SHA to help filling up gaps created by staff on vacation. Home health nurses in their late 40s and early 50s train young nurses who just start their new nursing career in this agency. The number of home health nurses has not increased in Frederiksberg because more young people move in and the elderly population has not increased as much. But there are more demands for SHHs all the time.

The next client is a smoker and drinker evidenced by the smell in his apartment and a bunch of liquor bottles in the shelf. He has had leukemia and now colon cancer for which he has colostomy. Trine is supposed to change the bag today unless he has already done it yesterday by himself. He says he did it and the tissue around the colostomy connection site is pink and not swollen. His apartment wall is filled with Dali and Klimt. His TV shows stock prices. I asked Trine if she attempted asking him to quit smoking. She says not until she has enough rapport with her client. Usually she does not mention such a thing until two months from the new encounter with a client. Otherwise, some clients ask for a replacement. Trine says she needs to assert herself in that kind of situation by apologizing and keep addressing and nursing them. Backing off is not an option, she says. It is for their health and shrewdness in establishing relationship is a key issue in home health nursing. I like her more and more.

The last client gave me a chill, not because of her wound but because of her whole situation. She has never been outside of her 5th floor dilapidated apartment for 11 years. The building does not have an elevator and it looks like it has been quite a while since any maintenance work was done. Trine knocks on the door and it seems like forever when she finally opens the door. Here is a small and soft-spoken old lady who barely walks using her walker. Trine warns me before she opens the dressing wrapped around her right lower half of her leg below the knee. She has had chronic ulcer on her left leg that was healed and now she has even more severe one on her right leg. It has been like that for a long time, maybe more than a year. Trine says she has refused to see doctor or have a doctor visit her. Only the agency wound care team visited her and treated the wound. She used to take antibiotics but now she is not taking any because of the resistance. She suspects Pseudomonas but it has not been cultured recently. She opens up the wound and green pus is everywhere, oozing out and down to her foot. The wound circles almost all the way around her leg. It must be at least stage three ulcer. Not quite to the bone level but pretty close. It is something that I would see in the States with the patient admitted in a hospital, getting Zosyn IV drip for days. I am puzzled. Why is she here in her tiny flat alone without Antibiotics? Is this the respect for client’s autonomy or some kind of system failure? I checked her pulse after asking for permission. The pulse is thready and slow but regular. Home health nurses rarely listen to heart and lung sounds unless the clients’ symptoms warrant as such. I do not understand if this is palliative care or regular would treatment. Even if it is palliative, one does not need to have pain from the wound. Maybe I am missing something.

Worker shortages

10 July 2007, Tuesday

Today is the second day for Salem nursing home. I got on a wrong train to Gentofte. When I realized I could still change the line, I quickly got off the train and changed the line. I am on time to meet Mrs. M, the director of Salem. In Denmark, people expect others to be punctual. Here, being punctual means being on time, neither early nor late. People apologize when they are early for an appointment. It is a country that lacks flexibility. Anyway, I was on time at 10 a.m. sharp. Mrs. M has designated a nurse for me this morning even if the nurse does not speak English well. The nurse Anni says she only started working at Salem two months ago and still learning things. She is one of three registered nurses in Salem. She says there are not enough educated nurses. The SHAs take over during the night, performing some of the nurses’ duty such as leading the four teams of SHHs, calling ambulances in case of emergencies, etc. But SHAs cannot pour pills to the medicine box. One of the main duties of nurses is to fill the two-week worth of small med box bins. The medicine box is similar to those in the U.S. with one box each for morning, day, evening, and night drug doses. Also nurses are responsible to schedule various shifts for SHAs and SHHs. It seems that nurses do more hands-off work and overall operation of the nursing home, while SHHs and SHAs mainly interact with residents.

Anni allows me to follow her on the morning medicine rounds. She tries hard speaking to me in English. Examples of medicine for one resident are Citalopram, Entreotabletter Pantoloc, Ibumetin, Kirexa, Marevan, Mirtazapin, Pamol, Simvastatin, Sumatriptan, and Viramune. Many residents have hypertension, high blood lipid disease, diabetes, and depression. Hjertemagnyl is an anti-coagulant that can cause internal bleeding. SHAs sometimes call doctors if they are suspicious of side effects of this medicine. Anni fills up total of 14 small boxes for next two weeks. Many different doctors prescribe all of these drugs. When one medicine runs out, nurse or SHA has to call each doctor for a refill. Sometimes after general physician refers a resident to a specialist, the dosage can change but the medicine chart does not get updated.

An SHA calls for Anni. Anni wraps up a resident’s prescription fill-up in hurry and goes to the staff office. For the next couple of hours, I have observed Anni’s frustration regarding an anti-dementia medicine Aricept. This is for one of three residents I have interacted with yesterday, Mrs. V. Her psychiatrist called in to check her current medicine and found out that Mrs.V has stopped taking Aricept. Nobody knows who stopped it. Anni and an SHA try to find the documentation in Mrs. V’s log. I sit and watch. Anni looks up on the computer records. Nothing. The SHA goes out and finds an SHH. The helper comes in to look at the log. Finally the helper finds a few lines of documentation about how Aricept was stopped. The log has a section that nursing home staff uses to document the nursing care. There is another section that doctors’ order is recorded. It turns out that Mrs. V’s daughter is a doctor and wanted her mother to stop taking Aricept. An assistant called Mrs. V’s general physician and got an approval to stop it. The assistant who handled it is on vacation now so nobody knows about it except the few lines of written documentation in the staff section of the log. There is no mention or record in the physician section of the log. Mrs. V’s psychiatrist did not know who stopped Aricept. The general physician apparently did not feel the need to contact the psychiatrist. Anni says doctors rarely visit nursing homes and ask nurses to take care of most of the health care. At this point, Anni looks confused and does not seem to be able to continue precepting me. That has been my brief interaction with nursing home nurse in Denmark. I am back at the garden where I was spending time yesterday.

Today is Mrs. V’s birthday and they made a birthday cake for her. Mrs. V’s family already took her to their house last weekend for celebration and today Mrs. V is alone in the nursing home with her friends. She probably does not know today is her birthday. I fed Mrs. M again today including ice cream and pear dissert. After the lunch, a helper and I transported Mrs. A to the weekly church service in the basement. About dozen residents came down for the traditional Lutheran service. Mrs. A says that usually a male minister comes to run the service but today his wife is running the service. She wears a neck collar that looks like the one a clown wears. She also wears a long black gown. I have sit in the whole service listening to a Danish sermon and many hymns. Out of five traditional hymns, I recognized the melody of one hymn. I tried to read the Danish lyrics.

In this first nursing home I have visited in Denmark, I am impressed with individualized care, innovation and idea of functionality in ergonomics, and standardization of health care policy. Individualized care goes all the way even to respect a resident’s wish to smoke. A helper has to move the resident to smoke outside every time he or she wants to. A group of residents help each other to form a smoke-break sometimes. But many times they forget to smoke from the result of dementia. At night, if residents do not want go to sleep and want to stay in the living room, they cannot be forced to go back to their rooms. Individual freedom is strictly respected exactly as they live in their homes. This IS their home. The helpers know each resident’s preference and character as time goes on. A couple of ladies always drink a glass of red wine together at lunchtime and they sit together for lunch. They look so cute.

The functionality of devices and furniture is improved but the difference is almost unrecognizable. A small wheel is attached to the front legs of normal dining room chairs and it helps move the chair close to the table with a resident on the chair. Without the wheels, it would scratch the floor and make squeaky noise but most of all it would be too heavy to move the chair. Nobody here uses the four-legged walker that is so popular in the U.S. Instead everybody uses the grocery cart type walker that has wheels. The walker has a small basket that they can carry their belongings. In the middle of the walker, there is a flat portion that they can sit on and rest. One of the residents goofed off by sitting a helper on her walker and pushed him to the living room for ‘her’ coffee break. I already mentioned the height-adjustable washbasin and dish sink in each resident’s room. Motorized lift device to move paralyzed resident to and from the bed is the most impressing machine. It would save helper’s back and at the same time be safer for residents too. There is no rotating motion to put the resident on the bed. This device will ease the hip pain many elderlies are suffering from. Bedside commodore also has wheels and a helper can move a resident from his/her bedside to the bathroom on the commodore. It would increase the mobility and safety. Wooden floor might improve resident safety and reduce the fall risk. Taking care of residents in 10 to 12 people in a group would be easier and cozier for residents and helpers as well. I asked the helper from Nigeria, Mr. Y, what level of facility class that Salem would belong to, high, middle, or low, among the Danish standards. He said Salem is an upscale high class nursing home but there are no big difference between all three levels of nursing homes. General nursing care and individualized attention are all the same in different class of nursing homes, he said. I imagine SHHs must work extra hard to fulfill the details of individualized care in Danish nursing homes.

height-adjustable washbasin in Salem resident's bathroom

I am back with the director to wrap up my two-day visit to Salem. It has been too short and I started to feel attached to residents and helpers. Especially Mrs. A has been really nice to me, asking for my marital status and my life in the U.S. Her sister and brother-in-law are visiting her this afternoon. She tells them I have come from the U.S. through Diakonissestiftelsen School of nursing. They praise the school and the foundation. Mrs. A keeps talking and I cannot leave. With the director in her office, I apologized her if I made Anni get confused. She said it was ok. She blamed doctors for not communicating with nursing home staff or other specialists in general. One of my questions about nurses was lack of clinical assessment by nursing staff. There are no regular vital sign checkups. Nurses almost never listen to heart and lung sounds. When I asked Anni, she said she was not taught how to do it. The director says that nurses should be aware of residents’ medical diagnoses and call doctors every morning to adjust any needed changes in the medication. Nurses discuss with residents’ family about the nursing home care. Nurses do staff scheduling every two months. Mental health care for the elderlies is one of the important aspects of nursing home care. She would like to introduce a therapy dog sometime and shows me an article about the effect of therapy pets on Alzheimer patients. Making the residents to feel good about themselves is the key through personalized care. She also emphasizes the policy implementation in nursing homes such as preventing bedsores by not allowing residents bed-ridden. Even if residents get seriously sick, they are moved about at least two hours a day and encouraged to stand up. When I mentioned Ms. E’s resignation, the director expressed the difficulty finding the new hire to fill up SHH positions. Probably SHH work is a bit harsh for Danes and foreign workers would have to fill up the positions. But it takes 7 years to get permanent visa and two years after that to obtain Danish citizenship. This number needs a confirmation but it sounds like the immigration rule in Denmark is strict. The director says there has been a heated construction boom recently and Denmark imported many foreign construction workers. There are 6,000 Indian doctors being imported to fill up the physician shortage. I asked if they would speak Danish and she said they would get by just speaking in English in the hospital. An Arab store manager in the poor section of Copenhagen near the Central train station tells me that Danish health system might be good but the medical and nursing education is behind and not producing enough well-educated doctors and nurses. Maybe that is why Danish health care is behind France or other Scandinavian countries, I thought.

Front-line Community Workers

What a week!
The last week has been an intense one with quite a ride,
literally with lots of bike rides. I am reflecting the
week and slowly writing my journals for the Community
course.

9 July 2007

Today I have met a 79-year young nice lady who speaks English very well. Her name is Mrs. A. She has had a stroke one and a half month ago and her left body has been paralyzed since then. When the Nursing Home director introduced her to me, she was exercising her wrists using a bike pedal machine. A middle-age physical therapist was helping a few other nursing home residents. The bike machines - those that users move pedals by arms not legs -- are placed on the corner of a square-shaped inner courtyard, with a glass ceiling all the way up to the second floor, surrounded by glass walls on all four sides. I can see what others are doing at the other side of the glass walls even people on the upstairs. The courtyard is filled with lovely plants, small tables and chairs. There are metal trellis, almost two-story tall, with climbing vines glittering with morning sunshine, which is rare one since it has been rainy and cloudy for the last couple of weeks. It is quiet and peaceful. It seems that the time has slowed down almost to stop, with the elderly residents enjoying their morning activities in a slow motion. This is a Nursing Home called Salem, meaning 'peace' in most Middle Eastern languages. It is a private nursing home in a municipality called Gentofte. The Deaconess Foundation administers and manages funding for Salem, together with Sister Sophie's nursing home in Frederiksberg. I am supposed to work with staff and residents in Salem for the next two days. I already like the atmosphere here very much.

The Deaconess Foundation (Diakonissestiftelsen in Danish) is 140-year old institution that has contributed in nursing education, medical care, and community health in Frederiksberg and beyond. The Danish Deaconess Foundation was established in 1863 on the initiative of Princess – and later Queen – Louise. The purpose was to provide Christian women with faith-based, compassionate nursing training. Deacons were later admitted. Today, the Deaconess Foundation provides care for children, the elderly, and the dying in particular, and offers community care services training. The nursing school I am privileged to be connected to for this summer belongs to the Deaconess Foundation. Gentofte is another municipality north of the Copenhagen city about 40 minutes on metro and S train. It is a charming and tranquil suburban town that is quite expensive to live even in Danish standard. Salem is an upscale private nursing home in Gentofte. It was built in 1963. Since the beginning, Salem has been built on the management and standard of the established Deaconess foundation. It was founded by a private donation from Johan V. Adolph who got the idea all the way into 1903, when he started a centre for convalescents on the place where Salem lies today. In 1963, it housed 44 residents.

There are still 45 elderly people living in Salem now. The building has been through an extensive renovation from 2003 to 2005 and the only unchanged structure might be the outside wall of the building. The inner structure contains four 'gardens' - 'Have' in Danish - that physically divide the nursing home residents. Their names are like Grete's garden, Mary's garden, etc. The four gardens are spread out in the two-story rectangular building with the inner courtyard at the center, with each garden holding 10 to 12 residents. Each garden has its own living room, kitchen, and dining room in the middle. The glass wall connects the kitchen and dining area to the inner courtyard from which the green plants and sunshine comfort the residents. The residents' rooms are located at the opposite sides of the central meeting place. About 10 times everyday the residents are transported from their rooms to dining room or living room, for meals, coffee or tea breaks, for watching movies, for song and dance, etc. The activity of moving the residents back and forth is intentional to help them wake up from their dementia, sleep, and boredom. There are three social and health care helpers ('social- og sundhedshjælper' in Danish, hereafter SHHs) assigned to each garden, performing daily routines of transporting residents, helping them wash themselves, taking care of their bathroom tasks, feeding them, and observing them for any changes in symptoms and behaviors. SHHs are the front-line caretakers for the community elderly care.

The three SHHs I met today have come from Thailand, Sri Lanka, and Nigeria. Another SHH, who came to help us from a neighboring garden, originally came from England. There are some older Danish SHHs in other gardens. The three SHHs helped me to get situated between residents on the lunch table. They have been very friendly, sincere, and honest to me. I have fed Mrs. M, an elderly female resident with Parkinson's disease. She could not move her body at all and only able to move her left arm to drink water in shaky motion. I am told she is able to speak English because she is half English and half Indian.

She has lived in India for quite some time. Her voice was harsh and sentence was short so I could barely understand what she was saying. She was also able to open her mouth just about half way and I had to chop up the food real small. She did not want any red meat so only chicken and fish were on her menu. Other residents’ meals were like that too. Each resident's food preference is strictly respected and there are even different choices of desserts for each resident. Diabetics get cakes with no sugar. SHHs work in three shifts, day (07:00 to 15:00), evening (15:00 to 23:00), and night (23:00 to 7:00), about eight hours each. I use the word 'about' since there seems to be flexibility in the time they can leave work. Most of the Salem residents have chronic diseases like Alzheimer's, Parkinson's, and paralysis after strokes. Also they are quite old, older than 80. I hear the oldest person is becoming 101 this year. A lady with big smile, who has worked as a nurse in the Frederiksberg hospital where I got my nurse uniform, is 94 years young. Another lady on her opposite side of the dining table is 96 and she still eats the whole meal by herself. Taking care of these ladies can be stressful sometimes, partly because of their physical and emotional dysfunction.

Two of the three SHHs commute from Sweden everyday because of the cheaper cost of living there. They say that the Danish nursing homes pay them more. But the guy from Nigeria, Mr. Y, expresses deep resentment about the Danish society. He is 26 and has a Sociology B.A. degree from a University in Norway. He came to Denmark with his family but he could not get a decent job using his major. Danish society demanded education from Danish educational institute. He blamed Danes not treating foreigners equally as themselves. He has been working SHH jobs in two nursing homes and was able to save some money though. He recently bought a car and apartment in Sweden. He says he does not have to pay much Danish tax if he only earns below the minimum taxable income per year, around 40,000 Kr. His girl friend drives his car because he does not have the driving license yet. He is going to take the license exam - driving test - tomorrow, which is his birthday. Later he would help me buy a used mobile phone in one of the poor neighborhoods in Copenhagen. Mr. Y and the SHH from England, Ms. E, had a discussion with me, after we transported all residents to their rooms for the afternoon nap. We had one hour before moving them back out for coffee and cakes. They explained the real working situation in Denmark. There is a serious worker shortage in Denmark. The turnover rates in the job like SHH are high. There was a strike and demonstration by SHHs a few days ago in Copenhagen asking for more workers. To be a worker like Mr. Y, one needs to pass Danish language exam and show fluency in communication in Danish. Many immigrants experience difficulties having command over the language, as well as being integrated into the society. Ms. E says another reason for nursing shortage is the low salary for nurses. The Danish government pays college students for their education and living. University students receive 6,000 Kr per month after tax and after tuition is paid. But the nurses’ salary compared to the minimum wage is quite low. The minimum wage is 98 Kr per hour, SHHs get 109 Kr./hr, and Social and Health care Assistants (SHAs) get about 118 Kr/hr. Nurses’ salary is not much higher than that right after their four-year education. A new nurse gets about 25,000 Kr/month and that is about 15,000 Kr/mo after 42-46% tax has been paid. SHAs need 18 months of training to assist nurses in nursing care. For Ms. E, even the SHH job at Salem is a bit stressful for her. Later in the afternoon before she gets off her shift, she tells me, waiting for the weekly staff meeting to be over, that she is going to announce her resignation to the nursing home director and move on to become a SHH for home health care. She can have more freedom and less stress and a bit more pay by doing the home health SHH. She says a guy from a home health agency called her this morning. She does not seem to be fond of the director or to be much concerned about the director’s own problem which she had discussed with me this morning. Ms. E does not think that the director is doing her job well.

I have been close to three residents today, Mrs. A, M, and V. Mrs. A’s room is very neat and clean. All rooms have wooden floor, height-adjustable wash sink and bed. Also motorized lift is installed from the ceiling to help transfer residents from wheel chair to their bed. I watched Mrs. A being ‘flown over’ to her bed by smooth operation by an SHH. She praises her SHH’s operation of the device. The SHH plays Mrs. A’s favorite CD softly. It is a jazz CD compiled by Mrs. A’s husband before he died of heart attack. Mrs. A showed me her husband’s pictures. Portraits of her two sons hang on the wall. She says she and her husband traveled all over the world including America. I can feel that she misses her husband so much.

Mrs. V’s room smells urine and I suspect she has some kind of bladder problem. She has serious Alzheimer’s disease to the level that when she stands up to go back to her room, she forgets what to do the next. The SHH has to keep remind her of her next move. Her emotionless face and lack of appetite worry me. But she thanks me when I move her to her bed. She does not need the motorized lift. Mrs. M had her cake in her room. I fed her a little while she was watching a TV cartoon.

The nursing home director Mrs. M has worked for the nursing home for a long time and about to retire in three years, according to Ms. E. Mrs. M gave me a brief introduction to Salem this morning. To be eligible to move to a nursing home like Salem, the community has to approve. Some residents do not have family to support them. All of the residents stay in nursing homes until they die. Each resident’s general physician and home health nurse play a big role in deciding if a person would need a nursing home care. Once that decision is made, the candidate is put on a 3-month waiting list to be placed in one of his or her three nursing home choices. Main principle is to place the elderly to a nursing home close to where they used to live. Applicants sign a contract about the financing of their nursing home care. Their pension fund is used up first. Also they pay certain amount by themselves. Then the rest of the cost is paid by the government though the municipal office. The fund is used to pay for the 55 employees’ salary, and the living and medical cost of residents. The cost of caring has increased recently and Salem spent 100,000 Kr more than the budget last month. Mrs. M is going to have staff meeting in the afternoon to discuss how to reduce the cost. Some of the residents went to a trip to Barcelona recently, Mrs. M said. I do not know if that is anything to do with the increased cost.

For me, I am a bit empty-handed because I have not been interacting with any nurse today. It is still not clear what nurses do in nursing homes. I asked Mrs. M to assign me a nurse tomorrow if it is possible. She says she would try.

Inner Courtyard of Salem Nursing Home, viewed from one of the 'garden'.

Functionality in Health Care

Too busy to write a long blog but here is a short one.

I had a 100% Danish speaking Lutheran worship service this
afternoon at the nursing home I have visited. Out of 5 hymns,
I recognized one song. The hymns were all written before 1870.
The nursing home was brand new and it was the most beautiful
and functional one I've ever seen. I am going to ride a bicycle
tomorrow to visit elderly people in their homes.

The schedules are tight but I will survive.

Danish health policy, uh quick one... they prohibit keeping
a person bed-ridden. Even turning nursing home patients
on their bed is not enough. Even if patients are sick, they are
supposed to get out of the bed minimum 2 hours a day.
So several times a day, they move about a lot. From their own
rooms to dining room, for a meal, coffee/tea and cake, to religious
service, to song and dance, etc. If the patient is really paralyzed,
then they use this wheel chair that falls backward to become
a reclining arm chair. Leg and body angles can be adjusted.
Innovations and functional improvement in ergonomics are used
to help individualize the policy according to a person's handicap
or need.

Very impressive.