Urologic Health Problems among Zimbabwean Women

The Romanian Journal for Psychology, Psychotherapy and Neuroscience www.irscpublishing.com

Volume 1, Issue 1 June, 2011

IS THERE ROOM FOR TESTIMONY AND/OR NARRATIVE EXPOSURE THERAPY AMONG PROFESSIONAL NURSES?

Jane Handina Murigwa Kanchense, PhD. Peace Country Health, Population Health Services, Grande Prairie, Alberta, Canada

Correspondence to: Jane Handina Murigwa Kanchense, The Ndaramo Wellness Initiatives, Suite 405, 604 – 14th Avenue SW Calgary, AB. T2R 0M8 E-mail: [email protected] Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



ABSTRACT Posttraumatic Stress Disorder is a condition that reached epidemic proportions globally, but there is still no corresponding public health attention and reactionary health and other social policies. This article is a conceptual analysis of ethical issues regarding modes of thought and practice in healthcare, focusing on the dilemma of the connections between ethical, moral and legal issues. A Zimbabwean nurse’s dilemma regarding morality, ethics and the law is examined and analyzed. This dilemma occurred during the course of her work both as a wartime community health nurse, wartime operating room nurse, a near death experience, and upon receiving a testimony from a wartime killer who had killed her colleagues. Ethical dilemmas remain a challenge among professional nurses, world wide. As legal and professional practice become more complex, so do the associated ethical issues. Key words: Narrative Exposure Therapy, Testimony Therapy, Ethical Dilemma, Culture, Post Traumatic Stress Disorder

Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



INTRODUCTION Healthcare professionals who are trapped by ethical dilemmas experience are at risk for developing Posttraumatic Stress Disorder (PTSD). PTSD is a condition that reached epidemic proportions in the multitude of devastating conditions such as the HIV/AIDS epidemic, natural and unnatural disasters, and other health problems.1 However, there is a lack of sufficient and appropriate public health attention and reactionary health and other social policies to address this issue. This article is a conceptual analysis of ethical issues regarding modes of thought and practice in healthcare, focusing on the dilemma of the connections between ethical and legal issues. Research Question Is Testimony Therapy and/or Narrative Exposure Therapy appropriate treatment options for a Nurse who suffers from Post Traumatic Stress Disorder? Broad Objective The ultimate objective of this report is to make recommendations as well as to provoke commentaries and responses on how a professional nurse may deal with ethical dilemmas when her own health is at risk. Specific Objectives To describe how the dilemma resulting from the intersection of culture, tradition, and ethical practice can exacerbate emotional pain among professional nurses 1.

To show how the manifestation of cumulative emotional trauma

contributed to Post-Traumatic Stress Disorder in a Zimbabwean nurse.




Definition of Terms Ethical Dilemma: “An ethical dilemma arises when two primary values conflict.”2 Testimony Therapy is an approach that refers to working with victims of political violence. Individuals who have experienced or witnessed human rights violations are encouraged to talk or write about their traumatic experiences with a view to promote emotional recovery and social justice 3-4 Narrative Exposure Therapy is treatment for trauma resulting from organized violence using ideas from Testimony Therapy and Cognitive Behavioral Therapy.5

This article is a true story about the dilemma of a female Zimbabwean Nurse, a typical rural Zimbabwean village girl whom we shall call Mutsa to protect her identity. At the peak of the liberation war in the 1970s, Mutsa served as a Registered Nurse with the volunteer team of the International Committee of the Red Cross. Following her service, Mutsa experienced PostTraumatic Stress Disorder. This article is an examination and analysis of the dilemma that Mutsa experienced during the course of her work both as a wartime community health nurse, and wartime operating room nurse. Her experience receiving a testimony from a wartime killer who killed her colleagues is also narrated. Mutsa served as a nurse in a variety of healthcare settings. Of particular relevance to this report is when she served as a Community Health Nurse under the auspices of the International Committee of the Red Cross (ICRC) in Manicaland Province in 1978. On Monday April 17, 1978, her colleagues, a team of three white male and one black male did not return to base. The next day Mutsa and a Swiss Medical volunteer drove to Nyanga in search of their missing colleagues. When they arrived at Nyanga police station, the officer informed Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



them that their colleagues were dead. The police showed pictures of the bullet riddled bodies and the Toyota Land Cruiser truck (that had the distinctive ICRC logo) that the deceased were driving when they met their violent deaths, as evidence. The surviving ICRC team attended the funeral of the deceased Black Zimbabwean man at St Joseph Cemetery in Mutare. That week, the ICRC immediately withdrew its services from this war-ravaged country.6 This withdrawal of ICRC services left this Zimbabwean nurse without employment. After the burial of her colleague, Mutsa retreated to her village where she stayed with her biological family. On the night of Saturday April 22, 1978, she heard gunshots that were so close that she felt her home had been attacked. Her stepbrother had been killed in cold blood. The Rhodesian military took his body early Sunday morning. Mutsa and her family have never known what happened to his body. She asserts that she can still hear the gunshots to this date, more than two decades after the fact. The following week, military personnel arrived at the home of this grieving family around 7:00 in the evening. They demanded that the family truck, its driver and crew to go and rescue a stalled military truck that night. Mutsa’s father explained that he was uncomfortable letting his staff venture out at night because of the military curfew. The soldiers gave him alternatives --- either do it or get killed. He complied. The truck crew left in the company of the military folk. This incident exacerbated fear among this already fearful and grieving family. The civilian family truck crew came back after about two hours – two long hours of fear and emotional pain among all family members. Mutsa shook uncontrollably, sweated and even vomited. She was relieved when the crew returned unharmed. Early the next morning, Mutsa’s father went to the nationalist fighters’ base camp to voluntarily explain the circumstances before they (the nationalist fighters/guerillas) confronted Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



him. On his way from the guerilla base camp, he was intercepted by a group of Rhodesian soldiers who were patrolling the area. They immediately arrested him. He spent that day at the military base camp. When he did not return, his family assumed that he had been killed by the guerillas. The next day, Mutsa’s anxious and fearful family received word that their father had been arrested. By the time the wife and Mutsa followed up on their father, he had already been transferred to a police station in the city. Mutsa then followed her father accompanied by one of her young brothers and a first cousin. On arrival at the police station, they saw Mutsa’s father sitting on the bare and cold cement floor. He had handcuffs and shackles around his legs, and was hungry, thirsty, and tired. Mutsa requested permission to give him food and drink but the duty police constable declined. Mutsa’s father said, “Mutsa, I want you to go to Rogers’s work place and tell him that dad was arrested yesterday.” When they left the police station, Mutsa’s young brother asked her whether she knew whom Rogers was. She sad she did not. The young brother chuckled and said, “Oh, dad is clever. Rogers is his lawyer.” Mutsa soon learned that Rogers was a white lawyer who commanded a lot of respect in the area. As soon as Mutsa made the report, Rogers called the regional police headquarters and challenged the police for the unconstitutional arrest. By the time Mutsa and her team arrived in the village, their father was already at home. The police had Mutsa’s father back to his home as soon as Rogers and the police commissioner completed their discussion. The release of Mutsa’s father by the police did not necessarily bring peace to this family, because they had more explaining to do with the guerillas. The old man simply said that he was not going back to the guerilla base camp. A few months later, Mutsa re-joined the civil service during the second week of August 1978, and worked as an Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



operating room nurse for almost a year. At the height of the liberation war in Zimbabwe, many planned surgeries gave way to surgical emergencies that comprised gunshot wounds necessitating shrapnel removal and/or amputations of limbs. The young Mutsa with a history of emotional trauma could not bear participating in so many amputations that she requested a transfer to a patient care unit. Her request was denied. After a while, she became emotionally numb. She dissociated herself in order to cope with the situation. She simply participated in the amputations without empathy for the patients. For her, participating in amputations had become a way of life --- part of her job. The liberation war ended by way of a ceasefire brokered by the warring parties and signed at Lancaster House in England on 21 December 1979. This development became known as the Lancaster House Agreement. At the time of the ceasefire, nationalist war veterans stayed in holding camps called “Assembly Points.” Following the elections in 1980, these war veterans were dispatched to their homes in batches. No public health programs were implemented to help them deal with the emotional trauma they had experienced during the war. The same was true of former Rhodesian soldiers. They too were integrated into the post-colonial Zimbabwean army, and it was business as usual. None of them had opportunities for debriefing before being deployed into the community. One can only speculate that debriefing, counseling, or other form of therapy was such a mammoth task that it was considered better not to venture into it. In addition, such an undertaking would open up a can of worms, as the old English language adage says. For a nation coming out of a guerilla war and previous opponents are required to work together, and trust is an issue, the “let the sleeping dogs lie” attitude adopted by the government was




probably appropriate. But this approach did not necessarily ameliorate emotional trauma that the both the former militants and civilians were harboring. Britain officially withdrew its authority over Zimbabwe on April 18, 1980. Thereafter, April 18 was deemed the day for officially celebrating political independence. Conversely, for Mutsa, April 18 became a constant reminder of the loss of her ICRC colleagues as well as her stepbrother. Former nationalist combatants were incorporated into the mainstream where they served in various capacities, depending on their skills. By 1985, this nurse had been a divorcee for four years and she was having a stable relationship with a new man in her life. The mid-1980s saw several clean-up campaigns that sought to rid the country of single females in Zimbabwe’s major urban areas. When this campaign affected her city of residence, she immediately got married out of fear of harassment and the possibility of a jail term. In January 1986, this now re-married Mutsa attended a job interview at the Ministry of Health’s Head Office in Harare. A team of six men interviewed her. Mutsa’s performance at the interview was reportedly “outstanding” according to the interviewers report to the nurse’s immediate supervisor. Mutsa was promoted to a management position in May 1986. In December of that year, she received a telephone call from a man who claimed to have been on the interview team in the Ministry of Health’s Head Office. The man specifically wanted to speak directly to this nurse even though it was against bureaucratic principles. He obtained permission to speak directly to Mutsa from her senior manager. When Mutsa answered the telephone, the man on the other Harare end said, “Hey, do you remember me.” He then gave a brief description of himself, to which Mutsa responded by saying, “Oh, yes. I think I now recognize you.” Then as if to initiate a form of testimony Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



psychotherapy similar to the Shona tradition, the man said, “When you mentioned the killings of your ICRC colleagues during the interview, I felt sorry for you. You know, I am one of the people who killed those ICRC guys. But after witnessing your performance at the interview, I always wonder how many useful future citizens have we killed in cold blood during the war. You know, we had been told that they were armed. So we stopped them. At this point, they behaved as if they were taking cover. So, we shot them and killed them. We had also spent the day drinking in the nearby hill.” Mutsa responded by thanking him for confiding in her. However, fear and anxiety gripped her. Mutsa had trouble sleeping. Her muscles were so tense that she says, “I felt as if someone was whipping me on my back. Massage therapy did not help.” She says that she has frequently heard the killer’s words ever since. The month of December became a reminder of this communication, and the fear it caused her. Mutsa lived in constant fear for her life, because she did not know whether the former combatant was signaling that he would come and kill her or harm her in one form of the other. Anxiety continued to mount over time and she started to experience flashbacks of the liberation war experience, shattered limbs and her whole operating room experience. However, she could not disclose her experiences, although she was always fearful of her safety. On one hand, Mutsa was bound by the Official Secrets Act, the risk of Crimen injuria and/or defamation charges should the person decide to sue, confidentiality requirements per professional conduct. On the other hand her cultural beliefs required her to reveal this information. Moreover, disclosing this information could result in her losing her job and nursing license, which were her main assets for a decent livelihood, as well as that of her Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



children and biological family. Besides, revealing this information would expose the killer to possible torture and a whole new addition to the PTSD would ensue. This decision was especially difficult because his motive for sharing the information almost a year after knowing this nurse, could have been an effort on the killer’s behalf to initiate testimony therapy. It has never been established whether the killer was experiencing PTSD too. This nurse was faced with an ethical dilemma of such a magnitude that she had no way of obtaining help with this problem. One day in December 1989, Mutsa experienced a near death experience. She suddenly collapsed, lost consciousness and was rushed to the Intensive Care Unit (ICU) where she received life support. This sustained her life, although medical tests failed to reveal anything physically wrong with her. Among the tests conducted regarded tuberculosis, HIV, systemic lupus erythermatosis, pulmonary embolism, heart attack, and other so-called routine medical tests. These tests did not reveal any medical abnormalities. The failure to identify the cause of the patient’s state of collapse frustrated the knowledgeable physician who said, “I do not know what I am treating. We might just lose her.” This message was directed to both the nurse’s close relatives and the nursing staff. Mutsa, who by this time was semi-conscious, also heard this information She felt as though she was sinking into a deep hole. Thankfully, her boss, who had been attending a managers’ annual Christmas party out of town, came to encourage her to hold onto life. According to Mutsa, the boss spoke to her as if he was cheering a football team. “He saved my life,” Mutsa often says. However, when she regained consciousness, she says she experienced a phenomenon that none of her patients had ever shared with her. Whenever she woke up from sleep, she felt as if her legs and arms were missing. By the time she felt them, she was ready to go back to sleep. Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



This frightened her. She was afraid of sharing her experience because she thought others would label her as mentally ill. When she finally informed her physician, he told her that it was one of the rare symptoms of morphine withdrawal, and that it would go away over time. In addition, Mutsa cried a lot after re-gaining consciousness. She says that it reached a point where she asked the nurses for permission to cry, so that she would not disturb the patient in the next cubicle. Permission was granted all the time. Mutsa says, “I always experienced a feeling of wellbeing after crying enough.” The post-crying feeling of wellbeing continued to improve over time. She was discharged from the ICU after three weeks, with a provisional diagnosis of viral pericarditis. Thereafter, this nurse experienced recurrent bouts of loss of consciousness for brief periods of time for several years. To her, medical reason failed and faith in cultural beliefs began. She utilized the services of a traditional healer, and the symptoms subsided. Although her symptoms appeared to have decreased, Christmas festivities gave her mixed feelings. On one hand Christmas reminded her about the 1986 telephone conversation that made her chronically fearful and morbid. On the other hand Christmas was a time to celebrate anniversaries of escaping death from the unknown illness that knocked her unconscious in 1989. Mutsa returned to work, but she had a different personality. Her memory faltered frequently. She experienced thought blocks that interfered with her work. She would suddenly stop in the middle of a sentence, because she would have forgotten what she was saying. When another person reminded her of the last word or phrase she had uttered, she would carry on for a while without problems. At this time her family thought she was mentally ill. These symptoms gradually subsided over a period of almost two years. Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



One Tuesday evening sometime in August 1993, Mutsa suddenly woke up as if in a nightmare. She said that it all began while she was listening to a radio show, “Chakafukidza Dzimba Matenga”, during which the panel was discussing witchcraft and death. She had just experienced a panic attack. She was afraid of sleeping in her house, but could not explain why. She went to the emergency room where she received a tranquilizer. She took the tranquilizer for a week and the symptoms subsided. The nurse shared her experiences with her mother who asked the nurse whether there was any important information she was harboring from the people. This nurse says that all she could do was cry, “because I felt trapped,” she said. After a few weeks, the anxiety and panic attacks resumed, and she saw a consultant physician who also prescribed a tranquilizer. She took the tranquilizer for several years with positive results. By the mid-1990s Mutsa could not tolerate seeing fresh wounds regardless of the size. Asked to explain the reason for such a turnaround from chopping shattered limbs to being personally affected by seeing wounds and/or blood from injuries of other people, Mutsa said, “I have no idea. I just can’t bear it anymore.” Mutsa has stopped clinical nursing, and avoids hospital emergency rooms. In early 2000, Mutsa’s father passed away unexpectedly while she was out of the country. She made arrangements with her family to schedule the burial for Sunday afternoon to allow her travel time. Unfortunately, due to circumstances beyond the family’s control, they were forced to bury the body on Saturday afternoon. When the nurse arrived, she was shocked to learn that her father had been buried. She was so aggrieved that she almost experienced a nervous breakdown. According to her, “I was shocked and aggrieved to find him buried because I had anticipated participation at burial would provide me with an opportunity for closure.”




Mutsa left her village at the end of February. Her goal was to return where she had come from. Unfortunately, she was arrested at the London Gatwick Airport and was detained under guard by armed security guards for fourteen hours, following which she was deported to Zimbabwe. Upon arrival in Zimbabwe, she had nobody to turn to for support. She requested help from her ex-husband, who surprised her by being very supportive. She finally proceeded with her journey in mid-April of that year. After she arrived at her destination, she was relieved that it was all over. However, anxiety and panic attacks increased in both frequency and intensity. She saw a physician whom, after interviewing the patient, concluded that she was suffering from PTSD. The physician prescribed an anti-depressant for her. She has taken this anti-depressant in varying doses depending on her emotional state since then. In May 2001, Mutsa’s spouse threatened to kill her. He told her that he would chop her with an axe. This appeared not to have affected Mutsa much because she immediately slipped out of the house and drove to safety. Her condition was so well controlled that she embarked on doctoral degree program in September of that year, while receiving treatment for exogenous depression, as her physician would say. She successfully completed the doctoral degree program within four years. In February 2006, Mutsa moved to a totally new country where she sought employment, and became one more addition to the millions of Zimbabweans in the Diaspora. The uncertainty posed by the challenges of a job search took its toll on her emotional health. In the early hours of July 24, 2006, she experienced what she has since dubbed the grandmother of all panic attacks. According to her, “I have never experienced such fear before. I felt as if I was going to die. At that time, I was concerned about my children’s ability to deal with my death. I was also concerned about their future.” When asked about Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



what could have triggered this so-called “grandmother of all panic attacks,” she said that she had been writing a journal article about the violence experienced by rural females during the liberation war when the symptoms began. Mutsa’s traumatic experiences remained encapsulated and trapped in her for a long time. The result was a seemingly “normal” successful woman. However, in real terms, this woman lived a double life --- what Dori Laub refers to as, “a robot-like semblance to normality with incessant haunting by nightmares and flashbacks.”7 Unsurprisingly, Mutsa made an objective reflection of her experience more than two decades after the first major traumatic emotional experience.

Analysis of the Case and Review of Relevant Literature It is no surprise that Mutsa was diagnosed with PTSD. Her personal history and brush with highly stressful experiences are consistent with those experiences that are known to cause PTSD. She was exposed to several highly stressful situations that include the violent killing of her ICRC colleagues and her stepbrother in 1978, a near death experience during a lifethreatening illness in 1989, detention under armed guards in 2000, a spousal threat to kill her in 2001, and the uncertainty posed by unemployment in a foreign country. Each of these situations threatened her life and/or bodily integrity. No links were established between her experience receiving the testimony from the killer in December 1986 experience and her illness in 1989. However, one can only speculate that the 1986 experience could have caused hyperarousal of Mutsa’s Autonomic Nervous System. If that was the case, then the 1989 experience could be interpreted as a manifestation of what Rothschild refers to as frozen state. Rothschild says, “PTSD develops: when flight or fight Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



(stress responses) is not possible; the threat persists over a long period of time; and/or the threat is so extreme that the instinctive response of the victim is to freeze.”

8-9

Surviving and

excelling through her nursing career as well as the intellectually demanding and emotionally draining doctoral degree could not have been a sign of psychological wellness, but a manifestation of an overactive amygdala, in response to ongoing threats on Mutsa’s life. The amygdala and hippocampal complex, two medial temporal lobe structures, are linked to two independent memory systems, each with unique characteristic functions. In emotional situations, these two systems interact in subtle but important ways. Specifically, the amygdala can modulate both the encoding and the storage of hippocampal-dependent memories. Hence these organs are associated with human emotion and memory.10 The basolateral nucleus of the amygdala (BLA) is under tonic GABAergic inhibition, and acutely blocking this inhibition results in increased anxiety-like behavior, conditioned avoidance, and sympathetically mediated cardiovascular activation and it is thought to have a significant role in regulating anxiety, autonomic responses, and the development of anxiety disorders.11 The cumulative impact of these experiences cannot be underestimated. Such bodies keep and maintain the trauma scorecard and affects not only the victim, but also society.12 Mutsa dissociated herself from the emotional trauma arising from witnessing amputations, in order to cope. Mutsa experienced several cycles or crops of emotional threat and PTSD. She developed temporary amnesia or disassociation, a natural response to threats according to Bremmer.13 However, Rothschild asserts, “While dissociation is an instinctive response to save the self from suffering – and it does very well – it also exacts a high price in return.” The price includes sudden reminders of the trauma, hyper-arousal, instant panic, and possible flashbacks.14 In fact, Bremmer et al. found that although it is inevitable, dissociation during a Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



traumatic may be a predictor of PTSD.15 The challenge was whether or not Testimony Therapy and/or Narrative Exposure Therapy would be treatment options for her, in addition to psycho-medication on which she has depended for almost two decades. Treatment Many psychotherapists and psychiatrists have recently recognized the benefits of psychomedication, Testimony Therapy, Narrative Expression Therapy to treat patients with PTSD. “Testimony psychotherapy offers survivors some therapeutic benefits in their trauma recovery.”16 Testimony psychotherapy works by disengaging fear in the mind.17 For example, former political prisoners, who gave testimony of their traumatic experiences from politically motivated organized violence under former Chilean President Augusto Pinochet as well as other victims of organized violence who used testimony therapy with their mental health professionals benefited from the therapy. They experienced diminished posttraumatic symptoms after therapy. In addition, Bosnian refugees and other individuals and groups in similar circumstances who received Testimony Therapy also benefited from this method of therapy.18-20 Narrative Exposure Therapy has shown promising results in the treatment of patients with PTSD.21-24 Advocates of effective treatment of PTSD recommended a combination of more than one of the three methods, i.e. Medications, Testimony Therapy, Narrative Expression Therapy when necessary. However, some authorities argue that psychological or critical incident stress debriefing is now thought to be potentially harmful, possibly because debriefing involves a group opportunity for the affected to talk about their thoughts, feelings, and reactions with the help of trained facilitators. Moreover, participants in such a setting may feel unsafe to share or simply not ready to share their feelings. The difference is that debriefing is often conducted Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



within 24 hours, while Narrative and Testimony Therapy are one-on-one therapy sessions, which are conducted when the patient is ready to do so. Barriers to Treatment Unfortunately health disparities affect patients in various ways among different individuals and groups. For many healthcare professionals of that time, speaking up about their psychological morbidity remains an ethical and cultural dilemma, because these mediating factors involve releasing information obtained in the course of duty for the most part. Legal and ethical issues challenge practitioners in using available options for the effective treatment of this condition.25-28 Ethical dilemma haunted health care professionals for centuries. As mentioned earlier, ethical dilemma is defined as an ethical problem in which the ethical choice involves ignoring a powerful non-ethical consideration.29 Ethical dilemma can affect the professional nurse in many ways. For example, by being a professional nurse, one makes a contract to meet society’s expectations. Professionalism among nurses is the basis of the nurse’s contract with society. Professionalism is therefore a reflection of ethical practice. "Ethics is central to the way we care, and to the way we envision ourselves as professionals…."30 Nursing professionals all over the world are guided by the International Code of Nursing Ethics which not only educates nurses about their ethical responsibilities, but also informs other healthcare professionals and members of the public about the moral commitments expected from nurses. Nursing ethics are governed by values.




Safe, competent and ethical care: Nurses value the ability to provide safe, competent and ethical care that allows them to fulfill their ethical and professional obligations to the people they serve. Health and well-being: Nurses value health promotion and well-being and assist persons to achieve their optimum level of health in situations of normal health, illness, injury, disability or at the end of life. Choice: Nurses respect and promote the autonomy of persons and help them to express their health needs and values, and also to obtain desired information and services so they can make informed decisions. Dignity: Nurses recognize and respect the inherent worth of each person and advocate for respectful treatment of all persons. Confidentiality: Nurses safeguard information learned in the context of a professional relationship, and ensure it is shared outside the health care team only with the person's informed consent, or as may be legally required, or where the failure to disclose would cause significant harm. Justice: Nurses uphold principles of equity and fairness to assist persons in receiving a share of health services and resources proportionate to their needs and in promoting social justice. Quality Practice Environments: Nurses value and advocate for practice environments that have the organizational structures and resources necessary to ensure safety, support and respect for all persons in the work setting.31 The professional nurse must learn continuously in order to know about new diseases and health conditions as well as new evidence of effective healthcare interventions. In addition, Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



professional nurses are also bound to their own cultural beliefs and practices, the traditions of the communities they serve. Many new health conditions and intervention strategies pose ethical dilemmas among nurses. Post Traumatic Stress Disorder for example, was unknown to the medical profession until the 1980s.32 This condition was treated with medication and cognitive behavioural therapy for the most part until the 1990s when Testimony Therapy and Narrative Exposure Therapy were discovered.33-34On one hand the World Health Organization (WHO) defines Primary Health Care as “essential health care based on practical, scientifically sound and socially acceptable methods… [my emphasis].” On the other hand, the WHO “reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience.35 The International Code of Nursing Ethics concurs with these Primary Health Care principles. It is imperative for nurses to uphold four key principles as listed below. Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and coordinate their services with those of related Groups.36 Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



The professional nurse must recognize and abide by the laws of the land. For example, a form of Roman Dutch Law binds Zimbabwean nurses in their capacity as law-abiding citizens. Those nurses who are civil servants are additionally bound by the Official Secrets Act [Chapter 11:09] which prohibits the “disclosure for any purpose prejudicial to the safety or interests of Zimbabwe of information which might be useful to an enemy; to make provision for the purpose of preventing persons from obtaining or disclosing official secrets in Zimbabwe” among other things.37 Within realm of guidelines and healthcare management protocols are cultural practices that compete with so-called professional practice among nurses. The Shona culture of Zimbabwe requires any individual who witnesses an unnatural death to go public with the information, lest the spirit of the dead person haunts her/him. In addition, nurses, like any other person in need of care, deserve the right to all available treatment options for improving and enhancing their health and quality of lives. SUMMARY AND CONCLUSIONS PTSD is a condition that has reached epidemic proportions in the multitude of devastating HIV/AIDS epidemic that has stolen the center stage in public health attention and reactionary health and other social policies. Cancer patients, HIV/AIDS patients, war victims, victims of natural and unnatural disasters, and many other categories risk developing PTSD. Yet little has been done to acknowledge this global public health problem. Mutsa experienced cumulative emotional trauma that contributed to the development of PostTraumatic Stress Disorder. A complex combination of problems in healthcare, strategies in healthcare delivery, cumulative emotional trauma from war-related and/or near death experiences, cultural beliefs or national traditions confront the nursing profession by posing an Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117



inextricable dilemma. This dilemma makes accountability such a huge challenge among profession nurses that it is hard for them to utilize Testimony Therapy and/or Narrative Expression Therapy, even when confronted with Post Traumatic Stress Disorder. Healthcare professionals that have been trapped between professionalism and PTSD such as Mutsa have the right to healthcare, just like those clients for whom they provide services. Professional nurses may utilize Testimony Therapy and/or Narrative Expression Therapy through the help of a professional counselor. The professional counselor who is also bound by her professionalism will maintain the information in confidence. Recommendations The recommendations from this case analysis are to build a solid foundation whereby healthcare professionals recognize PTSD, a situation whereby researchers and ethicists advocate for appropriate policy changes and the affected person is at liberty to be an active participant in her/his healthcare as follows. 1.

Considering the rate at which international travel, the global wars of the 21st

century, and the over-increasing numbers of victims of organized violence, healthcare curricula should incorporate PTSD as a health condition. Healthcare service providers, particularly frontline staff, must be educated and trained about clinical features of PTSD, available treatment options, and where clients can obtain Psycho-medication, Testimony Therapy, and/or Narrative Expression therapy as needed. 2.

The goal should be to develop policies that could bring these seemingly

insurmountable ethical dilemmas to a situation whereby victims of torture or any other form of emotional trauma for that matter can access and utilize available healthcare services. Kanchense, J.H.M. (2011). Is There Room for Testimony and/or Narrative Exposure Therapy among Professional Nurses?. The Romanian Journal of Psychology, Psychotherapy and Neuroscience, 1(1), 90-117


3.


There is ample room for Testimony and/or Narrative Exposure Therapy at the

intersection of professionalism and culture among nurses with Post Traumatic Stress Disorder. Nurses have a right to healthcare, as well as an obligation to keep themselves healthy.




REFERENCES 1.

National Institute of Mental Health, (2007) Post-Traumatic Stress Disorder. Available

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