One Nurse At A Time modules are intended to help nurses understand processes that are uncommon in our work practices at home. They are intended to be practical guides and not exhaustive dissertations. Education is a dynamic, ongoing process. We value your input and comments on the content of this module. Please feel free to write to OneNurseAtATime@gmail.com.
THE ROLE OF THE NURSE IN THE DEVELOPING WORLD or HOW DO I FIT IN?
This module is to help prepare you for what to expect on a medical mission. It does not contain treatment protocols or disease entities, but rather the emotional, interpersonal, spiritual and physical issues that arise from working abroad. We challenge you to examine your thoughts and beliefs about your place in the humanitarian environment.
As you begin working abroad, you will find saying, “I’m just a nurse!” won’t fly. You will be expected to work beyond your scope of nursing practice at home. Not only will you cross over within nursing (like ER nurses doing PACU or women’s health), but also doing other jobs you’re not trained for or skilled at: logistics, changing a Land Cruiser’s tire, hiring and firing employees, teaching, hospital administration, budgets, etc.
We offer other educational modules on the One Nurse At A Time website which focus on what a nurse needs to know when dealing with various medical situations rarely encountered in our home practices. Treatment protocols are internationally accepted standards of care endorsed by the WHO. As a healthcare professional, you may be expected to diagnose and treat without a doctor present and with fewer resources than you are accustomed to at home.
SCOPE OF PRACTICE
Let’s start with scope of nursing practice. We are all accustomed to working within our state or nationally defined practice standards for nursing. After all, that was how we were trained. However, nurses in the developing world have a far different scope. Nurses may very well diagnose, prescribe and treat as well as run programs and function as pharmacists. The term “nurse” loosely covers “Nurse Assistants” with several months of training, “Practical Nurse” with a year of study, “Professional Nurse” with a university education plus other variations depending on the country. Typically, the lesser the amount of training, the more hands-on the position. Often, nurses trained for a few months work in remote health posts providing basic health to a rural population. Even this basic level of nurse is expected to diagnose, treat and dispense, many times with few medications and little pay.
In some countries, nurses continue their education to become professional midwives. In other countries, nurse and midwife are two separate career tracks. In some cultures a midwife is called into the profession through a dream, their own or someone else’s. In most developing countries, women deliver at home for financial and societal reasons or in response to lack of available services. A hospital is often the last resort after witch doctors, traditional healers and Traditional Birth Attendants (TBAs).
TBAs have less or no formal training compared to midwives, but in some areas the terms may be interchangeable. TBAs may be sanctioned by the government or may simply be elder persons in the community, with skills passed down from one generation to the next. While usually women perform deliveries, in some cultures men are trained by their fathers in a long tradition of male TBAs.
Doctors also have a different role in developing countries. Doctors work in hospitals, universities or government positions and are upper managers and teachers. Many countries train Clinical Officers or Medical Assistants to give front line care in remote areas. The relationship between doctors and nurses is reminiscent of the patriarchal 1950’s American model – nurses taking orders without question or collaboration.
ROLE OF THE EXPATRIATE NURSE
Often expatriate nurses are expected to teach. First, find out what your audience already knows and what tools they have in order to build an appropriate lesson plan. I was asked to create a 2 week trauma course in Phnom Penh, Cambodia. My ER brain flowed with standard TNCC (Trauma Nurse Core Curriculum) protocols. But as I began doing my research, I found there was no 9-1-1, no Emergency Medical System, no backboards or cervical collars, no ambulances – only bicycles carrying limp bodies. People refused to donate blood because they feared contracting a disease. Nurses had no understanding of the concept of “titrating” meds – you give the dose the doctor prescribes. Large bore peripheral IVs were a dream in a place where the public self-injected medications. Instead of standing in front of a lectern, I shared stories and experiences and learned more than I taught.
Another mission in a remote corner of Darfur, my predecessor had taught staff about breath sounds, abdominal exams and the like. But after a week or so, I noticed our staff would count a pulse by grasping the wrist, looking at the clock and after a pause, pronouncing “60.” Their fingertips were on the dorsum of the wrist and the clock had no second hand. They had no idea what they were counting, how to count or what “vital signs” meant! After that, our weekly training sessions focused on the basics: hand washing (in a place where water was pumped from a well, carried in plastic jerry cans in a wheelbarrow to water containers located around the hospital and soap was a precious commodity), universal precautions (they had been told “wear gloves” when performing blood tests … so they wore the same pair of gloves all day long!), vital signs (what does blood pressure measure and what does it tell you about your patient), basic math and counting, and other rudimentary concepts. By the end of six months, we’d turned non-medical staff into an independently functioning medical team.
PREPARING TO GO or CAN I REALLY DO THIS?
There are obvious suggestions about learning about the place you’re going by reading, watching videos, talking with those who have gone before, etc. But what we want to suggest is for you to clarify your personal values and boundaries.
Know your feelings about right and wrong, abortion, religion, the role of women, marriage and politics. How will you explain your views to others who don’t have the same religion, culture or background? Make no mistake, people will be interested about what you think and will ask your opinions. Few outsiders may visit the locations you’ll travel to. You will need to find a way to balance the exchange of ideas without offending, dominating or misrepresenting and still remain true to your beliefs.
Especially in conflict situations, it’s easy to lose the notions of medical ethics and neutrality. It’s easy to see black and white, but one side’s good guy is another side’s bad guy. Working in remote western Ethiopia, our local Nuer and Anuak tribes routinely had their cattle stolen and populations decimated by the murderous marauding Murle tribe of bordering South Sudan. On the other side of the river, the Murles were beloved, kindly and fearful of the killer Nuers. Remember, as a medical professional, it is your obligation to treat whoever comes to you for help.
How will you manage if you have to compromise medical standards you hold at home? What if you don’t have the tools, drugs, information or accessibility of follow up care you normally rely upon? For example, picture yourself in rural Africa or Indonesia or India and you come upon a new onset A Fib or diabetic. What do you do? You have meds for 1 or 2 weeks … and then what? Do you give insulin when it’s 120 degrees, and the patient has no means to keep it cool? Do you start digoxin or beta blockers without an EKG or sustained supply of medications? What about long term chronic illnesses – how will you handle hypertension or cancer? You may be called upon to care for many without the means to fulfill that request. Treatment for these conditions may be outside the scope of your host organization. How will you feel? What will you do and with whom can you discuss these questions?
Expect things to be different than what you’re used to. Expect boundaries and ethics to be different. Medicine can be political, withheld or used as a weapon against certain groups. The importance of tribal affiliations and politics can’t be underestimated. Ethnic groups that are out of favor with those in power may not have the same rights to healthcare. Even something as universally accepted as vaccinations may be less available to marginalized populations.
Sometimes religious beliefs and personal convictions can conflict with providing medical care. At a women’s clinic in Belize, a volunteer nurse found herself navigating around the district public health nurse who withheld immunizations for children of a mother practicing contraception. Though not the official stance of the country’s public health system, individual practitioners were given a wide berth when it came to matters of their own religious convictions. Another example to consider: how do you teach HIV prevention in Catholic societies opposed to the use of condoms?
Unbelievably, a district director of the Ministry of Health in Uganda refused to allow ACT (Artemisinin Combination Therapy) malaria medications to be used even though it was the federally approved protocol. Why? Because he had a financial interest in several pharmacies in the area that had stockpiles of two drugs no longer effective against malaria. Until his two worthless medications had been sold out, he raided clinics and removed any ACT he found. When asked what medications he would use for himself or his family should they contract malaria, he refused to answer.
MEDICINES or WHEN DID I BECOME A PHARMACIST?
Medications can be a real challenge. An excellent resource is the WHO list of essential medications. A free download of Doctors Without Borders Essential Medications and Clinical Guidelines can literally be a lifesaver: http://www.refbooks.msf.org. Where There Is No Doctor and Where There Is No Dentist are good support texts if you’ll be in rural areas with little access to health care (www.Hesperian.org).
A note of caution: You may not have access to the internet or computer or satellite network, and your handheld mobile device may not get reception in the developing world. You may not even have access to electricity for recharging! Be sure to bring hard copy pharmacy information and treatment protocols with you.
- You may need to make your own pediatric liquids by crushing adult tabs/capsules and adding water.
- Drugs have different names, strengths and routes of administration. Instructions may be written in languages other than English.
- Some medications are in glass ampules and come with a tiny metal file to score and break open the ampule.
- It is estimated that up to 30% of medications available on the international market are counterfeit!
Start simple. First line drugs WORK – amoxicillin, acetaminophen, metronidazole, dicloxacillin. Moving up to third generation antibiotics causes drug resistance. Drug company “free-bees” are not the best thing to bring with you. Think of sustainability – what happens when you are no longer there to supply medications? What’s available locally? What recourse will they have later when the second or third line fail?
Many patients have never had medications, so they have no idea about allergies. You’ll rarely see allergic reactions in the developing world. Not to medications, not to peanuts nor environmental allergies.
THE NURSE AS AMBASSADOR or HOW TO AVOID STEPPING IN IT
As much as we each want to be accepted as individuals, we do in fact represent our country of origin, our religious and sexual preferences, our gender and our profession. An uncomfortable fact for many Americans is the very visible political position of our country on the world stage. We have been seen as interfering in the world’s affairs and also as savior. People in countries you visit may indeed like you as a person, but like/dislike America as a nation for political postures and actions. Depending on what’s happening in the world at the time, you may find yourself questioned or challenged even by officials where you volunteer.
Not only Americans are branded with national stereotypes. British, French, Canadian, Chinese citizens are painted with the same brush as their government positions and international relations. For example, the high esteem held in Africa for Barack Obama meant Americans were generally welcome. Before his election, Americans were constantly challenged to defend the policies of the US government. Canada is often seen as an extension of America. The French and British were colonial powers in Africa and Asia – some countries still hold animosity towards them. Be alert for threats against you based on your nationality – unfortunately, this is no longer an uncommon occurrence in the humanitarian world.
You, as a nurse travelling and working internationally, will have to be prepared to answer these charges and navigate potential minefields of resentments and political dogma. Be open, not defensive, and approach conversations as a sharing of ideas.
Different societies will want to share their religious faiths with you. Think about how to sensitively represent your views without criticizing or ostracizing others. You may choose to remain neutral on this topic depending on the situation – not all religions are accepted in all areas of the world and you may put yourself at risk for “proselytizing” even if that is not your intention. Proselytizing is legally prohibited in some countries and frowned on in others.
Your ambassador role continues with official pleasantries, speeches, trophies, certificates and parties at the beginning and end of missions. You will be expected to participate, speak, dance, etc. Learn a few words and phrases in the local language. “Hello,” “Please,” “Thank you” go a long way toward creating goodwill. Teams will even create skits to perform. Go for it! Bring one nice outfit and pair of shoes for parties. You may also be asked to speak and/or be photographed for local television and newspapers. Be gracious, focus on the value of the work and the organization you represent.
Be careful with taking photos. Imagine how you would feel if someone took a photograph when you or your child was ill or disfigured. Ask permission first, with a smile and preferably in their language. Honor a denial of permission. Show the picture immediately after snapping. Some places have security sensitivities and photography is forbidden. Ask your hosts what is the appropriate approach to picture taking.
One of the most important nuances for you to recognize and understand is balance of power. As a nurse from a developed country, you have personal and financial freedoms, are usually able to travel and are not bound by gender or race. Your cohorts in the developing world do not have these same options. Whether or not you intend it, you enter into a position of relative power. This imbalance can lead to abuses. Stories abound. The most disheartening was a 2002 UNHCR report of the Mano River Union (the border of West African countries of Guinea, Liberia and Sierra Leone) where humanitarian workers were documented trading their services for sex in Internally Displaced Persons camps.
Relationships can become intense very quickly. Patients and staff may ask you for financial help, money for school, help to go to the US, etc. Be prepared with your answers – respond kindly but firmly. Don’t make promises you can’t realistically keep. It’s easy to get caught up in the passion of the moment especially with people you have become close to. If you are honestly inclined, investigate the possibilities and legal consequences first before making a commitment. On the other hand, you may be given gifts from families. They may give what they don’t have out of appreciation for you coming to help. Be gracious in declining or receiving.
It goes without saying you’ll need to be culturally sensitive and dress appropriately for the location – during work hours and also off duty. Understand you will be on display 24/7 with eyes and ears on everything you say and do. You may find yourself feeling much like a gorilla in the zoo. In Pakistan ten years ago while our surgical team was sightseeing, a young man shoved a boy in front of me, snapped a photograph, grabbed the boy and ran. Little African kids will run after you shouting your name, ”howareyouhowareyouhowareyou” or terms like “muzungu” or “kawaja.” What starts out as cute can turn annoying when it happens non-stop.
PERSONAL CARE or BASIC SURVIVAL TECHNIQUES
You might be going halfway around the world, crossing multiple time zones, experiencing jet lag yet are expected to function immediately the day after arrival. Consider using sleeping pills to get past the first week or two – on average it takes one day per time zone to acclimate. Bring books and music and things that soothe you. I always take lotion for my feet, a feather travel pillow and an LED headlamp for reading in bed when roommates want to sleep. Bring pictures of your kids, family, home, vistas and share. Homesickness can overwhelm you, especially when there is a lack of internet or telephone connections. Keep a journal and document your days, your activities and your thoughts and emotions.
Bring something to keep in your pocket for between meals – nuts, granola bars, etc. Eating times are different than at home, you may not like what’s served or you’re simply too tired to eat and just want to go to bed. It’s hard to be vegetarian in the developing world. A friend strictly adhered to a vegan diet in Liberia until she discovered fish scales in her vegetables – the cook had made her plate “vegetarian” by simply removing the meat/fish after cooking everything together in one pot!
It’s not unusual to be overwhelmed at first. Exhausted, you’ll be working 14 – 16 hour days but feeling like you should do more. There are always more patients. Sometimes patients come just because you’re a foreigner, and they hope you can help when they know you can’t. They may even invent problems in order to receive something free from you.
Bring small gifts for your coworkers/national staff. On surgical trips, plan to bring gifts of click pens (uncommon in other countries), trauma scissors, books, stethoscopes, notebooks, giveaways from your workplace, etc. The national nurses will give you things, and it’s nice to reciprocate. Plan to leave behind your scrubs and surgical caps, etc. Expect on the last couple days of a mission, things will go missing. Nothing will be touched during the mission, except at the end. Think of small things you can give: fingernail polish (even the boys like it sometimes), little hair clips, stickers, colored pencils and sharpeners and crayons. Be careful to give equally.
A note on security: Be careful with your things. Cash and valuables like iPods and computers are easy targets. Even when reassured “It’s safe here,” keep your valuables with you.
After an intense week or two, it’s hard to leave. But the memories and lasting friendships are the biggest gifts you’ll ever receive!