Portal de Periódicos da CAPES

Improving Health Care in an Underserved Setting

2009; Wiley; Volume: 89; Issue: 5 Linguagem: Inglês

10.1016/j.aorn.2009.04.011

1878-0369

Charlotte Souers,

Nursing Education, Practice, and Leadership

Service learning can be defined as academically based community service, such as a structured learning experience that combines community service with learning opportunities that are intentional and provide for periods of reflection.1 Although there are many opportunities in our communities for nursing students to apply their knowledge, the opportunity to provide a much-needed service in a different culture adds an additional dimension to education. By providing basic health care on an international level, the student is exposed to global public health issues. This creates an opportunity to participate in improving health care and to have an effect on issues such as hygiene, environmental health, and sanitation. This was the goal of a Nursing Field Studies course developed at Ohio University, Athens, in 2007. The Nursing Field Studies course was coordinated with the Office of Education Abroad at Ohio University to offer students a cultural experience through providing health care in a clinic setting in an underserved country. Participating students were part of a medical team that traveled to the Dominican Republic with the aim of providing screenings, diagnostic testing and assessments, and limited treatment to five poverty-stricken villages. An additional goal was to provide educational experiences to a small group of volunteer health care leaders, known as "healers," in the villages. The students who participated in this course gained a sense of professional volunteerism as well as a cultural appreciation for health care in different settings. This article describes this innovative approach to involving students in an international effort to effect change in a community's health care status. I have previously participated in mission work with several nonprofit organizations. Some of the mission experiences were of a medical or surgical nature; however, my participation with Village Mountain Mission, a nonprofit humanitarian organization, consisted of helping to build adequate housing for selected families in a mountain village in the Dominican Republic. Through these experiences, it became apparent to me that the health care there was inferior or absent. Clean water, skin care, food storage and preparation, sanitation, and animal safety were some of the basic issues I recognized as being deficient. Education regarding growth and development, as well as proper child care and care of pregnant women, was needed. With this knowledge, I began the process of completing a needs assessment and brainstorming for possible interventions. I completed the needs assessment in collaboration with the Village Mountain Mission2 (VMM) director and medical director of the board. We developed the medical mission from the information gathered during the needs assessment. The medical mission provided an expansion of VMM services, which created the need to recruit medical professionals who were willing to serve as health care providers in this underserved setting. I also saw this as an excellent opportunity for nursing students to participate as part of a medical team, and to develop professionally in a volunteer capacity. This would enable them to begin making a difference professionally. The people of each village we served were eager to participate with the health care team members in providing services that they were capable of providing, such as registration and crowd control. The question remained, would they be eager to learn about health-related issues? After the need for health care was determined, the VMM board began the process of creating the opportunity for health care professionals, including nursing students, to travel to the Dominican Republic to provide basic medical services. A faculty member from the Ohio University College of Medicine who was my partner on the VMM board and I, a nursing faculty member at the School of Nursing at Ohio University, coordinated the development of the medical mission in 2007. I decided to implement the medical mission as a study abroad program for nursing students3 and my colleague decided to offer the experience to medical students. There were many advantages to adding the study abroad program to the Ohio University curriculum. First of all, many of our students are not exposed to multiple cultures in their nursing education experiences. I felt that working in an underserved country in a different culture would be a significant opportunity for students to experience diversity and to apply their skills in a very significant and meaningful manner. Ohio University administrators also saw this program as a means to promote the college's culturally sensitive nursing curriculum. The associate degree and baccalaureate degree programs emphasize individual as well as community focus. Being community focused incorporates not only being aware of local or national health care issues but international health care issues as well. I felt that outcomes or experiences from the study abroad program could be discussed as appropriate during various other courses within the nursing curriculum. Information could be shared when topics such as sanitation, hygiene, and therapeutic communication are discussed. The program was ultimately offered for three years at Ohio University as an elective course. The concept of the study abroad program transformed into a Nursing Field Studies course. I developed the course content, the course syllabus, and the implementation plan for the course. The course was offered to prelicensure associate degree students as well as baccalaureate nursing students in the RN-to-BSN program at the university. Thus, it was a dual-listed course posted for four hours of academic credit. During an orientation session, I introduced experiences that I had gained during previous mission trips to the Dominican Republic and other areas. Topics such as culturally sensitive health care, nutrition, and basic needs, as well as professionalism and professional organizations, provided the opportunities to share pictures and culturally specific information with students during their nursing courses. This was done not only to promote the study abroad class but to engage the students to be culturally sensitive in clinical settings. I held an information session on campus in the fall to introduce the Nursing Field Studies course to interested participants. During the information session, I gave a slide presentation to show photos of the Dominican Republic where the clinical trip would occur. Other details such as the course description, dates, fees, and expenses for immunizations were discussed. I presented information on topics such as housing, safety, food and water, and communication while there, and I distributed application packets at that time. Approximately four months later, I held a predeparture orientation session for the nursing students who were enrolled in the course. This was held approximately three months before the clinical trip to allow the students to become more thoroughly informed about the nature of the mission work and the primitive conditions in which the group would be living before they actually signed up for the course. The nursing field course syllabus detailed the course objectives, including clinical objectives related to the services that were to be provided.4 The objectives for this course also included gaining an appreciation for the concept of professional volunteerism and developing a sense of cultural adaptability. These were important issues to discuss as part of experiential learning. The classroom requirements for the Nursing Field Studies course consisted of predeparture sessions and activities and post-mission meetings, and there were clinical requirements during the mission. I limited the number of students enrolled in the course to 10. During the first and second years, eight students enrolled compared to approximately 15 students who attended the initial information sessions. Three weeks before leaving for the Dominican Republic, I held a joint meeting with all the students (ie, nursing, medical); participating community health care professionals (ie, nurses, nurse practitioners, physicians); and my colleagues from the College of Medicine who also served as the university faculty members. This was a recommended session for all mission trip participants to allow them the opportunity to meet and become familiar with one another before departure, as well as to enhance camaraderie and teamwork during the experience. Also, predeparture details and explanations regarding living conditions, food, security, and clinical activities were given to all participants at this meeting. A third activity was to attend a class on campus two weeks before departure. This class consisted of completing a Cultural Learning Strategies Inventory,5 a self-assessment activity to allow the students to assess their cultural tolerance and adaptability, and an open discussion of cultural differences between the United States and the Dominican Republic. These exercises proved to be beneficial because the students did not realize how their attitudes and openness would be directly influenced by a different culture. After returning from the mission trip, the students expressed that they were grateful to have discussed cultural tolerance in preparation for immersion into a different culture, as well as to have discussed the unexpected cultural adaptation of returning home. The class gave the students an opportunity to ask questions and to review packing needs, necessary paperwork, and other travel details. Throughout the orientation and predeparture sessions, the students were informed of the planned activities for the clinical experience. There was the caveat of being flexible because plans and clinics could change based on location and availability of transportation and the use of shelters in the villages. Clinical activities during the mission trip consisted primarily of participating in the clinics in the five remote mountain villages. The mission trip lasted nine days. We had groups of two students at each of the assessment stations. We saw ranges between 80 and 140 people during each day at the clinic, and each day, the clinic was held in a different village. This course has been implemented three times. During the first year in 2007, there were two medical teams. Each team consisted of physicians, nurses, medical students, and nursing students. The nursing students were supervised by RNs on both teams. Their roles at the clinics included registering patients, taking vital signs, gathering basic laboratory results, and assisting wherever they were needed. The nursing students were introduced to several basic and important perioperative nursing concepts during their time in the clinics. All of the staff members felt that infection control was a very critical issue, not only in implementing health care, but also in teaching the people of the villages. The students used aseptic technique when doing fingerstick procedures for testing. Sharps containers were prevalent at all pertinent stations. During the first year, an oral surgeon accompanied the team. This provided the students with the opportunity to assist in performing preoperative assessments and review important safety questions before the procedures. The students observed and assisted in cold sterilization of instruments. They also performed in the role of the surgical assistant during procedures, using critical thinking skills regarding airway management and surgical site exposure, as well as learning to anticipate the surgeon's needs. These experiences especially required that they be adaptable in different settings and at the same time maintain the importance of the principles. Students rotated among these roles to experience each station. At other times, students requested different roles, such as helping with the pharmacy or entertaining the children in the waiting area. The two teams alternated in working at the clinics. Cultural experiences included working closely with not only health care professionals who had varying health beliefs but also working with healers in a different culture. After the evaluation process in 2007, the VMM board determined that for the second year, there would be two teams traveling at different times. One team would consist of health care professionals and nursing students with the primary focus of educating the healers, while still providing clinics for the poverty-stricken people. In the second year, the Nursing Field Studies course was made up of a total of 13 participants, including a physician, a nurse practitioner, nurses, and nursing students. Most days were spent in clinics, where the nursing students rotated between the roles or assisted or shadowed the nurses, physician/nurse practitioner examiners, and the pharmacy. This gave the students the opportunity to learn about all aspects of the clinic. The make-shift clinics were set up by the medical teams themselves in the communities being served. Schools, churches, and community buildings were used. The students provided community-based care for an underserved population in a very basic setting. Through this experience, the students observed the diversity of the living conditions as well as extreme poverty. Interpreters were provided to assist with communication with the villagers. Medical history cards were completed at each station by the health care professionals, and medication for parasites was given to all non-pregnant patients. During the second year of implementation in 2008, the course included an additional requirement of providing educational sessions to the healers. For this, the students prepared a topic that was assigned during the predeparture orientation session. The VMM director, through a selection process, chose five women from the villages who were eager to learn first aid and basic health care to provide continuity of services after the missionaries left. The selection process occurred during the year before the mission trip. These women became the healers of the communities. Teaching the healers was an opportunity for the nursing students to provide teaching-learning sessions. These educational sessions consisted of proper hand washing concepts and technique, cardiopulmonary resuscitation, taking vital signs and initially interpreting them, obtaining simple laboratory specimens and interpreting the meaning, wound care and bandaging, well child and infant care and safety, care of pregnant women, and basic medication administration. Handouts were prepared by the students in English and Spanish. Each healer received a notebook in which to store her materials. At the completion of these sessions, we presented the healers with certificates of completion and gifts. Through these efforts, the students had a lasting effect on individuals who were enabled to provide continued important health care services to their village. After returning from the medical mission, an optional class activity was to attend a summary session, to which the students' family members also were invited. Pictures were gathered and digitally shared by students at this time. Family members were able to experience the cohesiveness that the group achieved from working and living in close quarters. They also were better able to appreciate and understand the stories that they were hearing and the new friendships that the students had formed. Another class activity after returning was to give a presentation about the mission trip. The purpose of this was not only to share experiences but to continue fostering a sense of volunteerism and service. Some students presented to community professionals as an information session on what is happening in their community in Ohio and potential opportunities for involvement in mission work at varying levels. Some students presented to nursing students to promote the Nursing Field Studies course, and others presented to civic organizations that may have financially supported them. goals—a description of personal and professional goals for the experience; thoughts—a description of thoughts on volunteerism; a daily log of activities; and observations—descriptive content regarding observations of cultural habits, people, group dynamics throughout the trip, and their adaptations to these. Another important aspect of the journal was the reflective return section, which allowed students to reflect on their reentry to the United States. This pensive reflection of how they had changed, what they learned, and what they would like to share with others gave students insight into their personal and professional development. Another concept that they considered was how they would use what they learned from this experience in their future professional practice. The journals were due within two weeks after returning from the mission trip. Most of the journaling was completed during the trip. The required content of the journals was designed to allow the students to express their thoughts about the criteria, as well as to keep a daily log of activities. Evaluation was an ongoing process for the medical teams, as suggestions for improvement arose regarding the flow of the people through the stations. The students gave wonderful suggestions to better utilize the local healers and other village helpers within the stations. Debriefing sessions were held on the last day in the Dominican Republic each year, where discussion and brainstorming helped us evaluate the experience and make constructive suggestions for future missions. The students felt that more time should be devoted to educational sessions with the local healers, as well as to the clinics, instead of the cultural activities (ie, entertainment activities and tours of the surrounding area). Also on this day, the teams formally collated the data gathered from the completed medical cards. Demographics were gathered as to the gender, age groups, and diagnostic groups. Examples of the diagnostic groups included musculoskeletal issues, cardiovascular conditions, and skin disorders. This would better enable the providers to prepare to meet the health care needs of the villages. Thank you for the opportunity to complete this type of mission work, I learned so much about myself in the process. I walked away with a more open mind and more respect for another culture and feel that I am a better person. (A. Myers, student evaluation excerpt, 2008) Faculty review of the journals was an enlightening process. Student testimonies were very positive regarding the educational experience, but most comments reflected thoughts regarding the teamwork of the mission group and the bond that developed between the community and the group. Students repeatedly spoke of how humbling the experience was, their increased awareness of cultural diversity, and the importance of accepting others' practices. Some students spoke of their desire to re-evaluate their life's goals. A personal high for me was becoming so close to the Healers. It was as if our hearts just connected through our work. A professional high was working in the pharmacy. It was a confidence booster by being amazed at how much about the medications I knew. …[I have] changed so much from this experience…. [I have] a different perspective, different priorities…. [It has] intensified my drive to stay actively involved in my community searching for more volunteer opportunities. (J. Beauman, student journal excerpts, 2008) I don't think I have ever done anything so rewarding…. Part of me wants to stay and help these wonderful people…I felt our group made a big impact on the Healers. …there was a great deal of collaboration with each person working to figure out the best plan…the feelings were that of a family…we had each other and needed each other…I feel like I had the pleasure of working with the best staff in the world. (K. Baikov, student journal excerpts, 2008) There are numerous resources available to help nurses become involved in mission work. Membership in a professional organization supplies access to a great deal of literature regarding these opportunities. AORN members, in particular, have the AORN Journal and AORN Connections. Both contain articles regarding members' experiences with humanitarian efforts at various levels. Other affiliations, such as religious or community groups, also can provide opportunities. Perhaps the most difficult aspect will be finding the "right fit" of activity and beginning the process. Searching the Internet will identify resources for volunteer activities. Volunteer Match is an organization that will specifically match a request and location with the opportunities that are available.1 Word of mouth is one of the most effective methods of sharing experiences to encourage others to become involved and giving guidance in the process. Mahatma Gandhi once said, "Be the change you want to see in the world."2 Indeed, each person can make a difference in another's life, however minute it may be. If each of us contributes in this way, we can make a cumulative impact on society. …professionally it was great to put skills to use in another country and having the ability to help others…it was also great to see the healers taking such an interest and knowing you had an impact and were involved with teaching…[it] was a great sharing experience. (C. Owens, student journal excerpt, 2008) This experience provided a more positive insight as to how different systems work…. I hope someday to go back and learn more and to help more. (J. Beauman, student journal excerpt, 2008) The comments from the students showed that the Nursing Field Studies course was a life-changing experience for them, both personally and professionally. The knowledge of skills, the intensity of collaboration, the compassion of a gentle touch during assessment, the giving of knowledge, and the receiving of unconditional and genuine kindness were experiences felt by all participants of this course. The healers were very appreciative of the team's efforts. They were very responsive to the educational sessions and strived to perform the skills accurately and to understand the results. They enjoyed the opportunity to learn the skills as well as to demonstrate them back to the nursing students who were their teachers. At the certificate presentation, one healer spoke in appreciation of our efforts by saying the group was like angels from heaven coming to teach them. Many of the healers asked the team members if they would come back the following year. It was very satisfying for me to see the students in the role of teacher, and I took great pride in the completeness of their presentations as well as the resultant learning by the healers. This actually added another dimension of professional volunteerism for me. I had participated in medical missions by providing health care, but to oversee my students contributing to the education of a community was very gratifying. The students' interest in professional volunteerism was developed from the seed planted in the classroom and by example, and many of them vowed to continue to serve others in some similar capacity after they completed the course. In fact, two students who went on the first trip returned the second year. The idea of respecting other cultures was personified in this experience and became a reality, as it had not been in their previous clinical experiences. The mission work of the VMM has progressed from assessing health care needs of a community to providing clinical services to the underserved to creating and supporting a structure that will provide continuity of care to an otherwise underserved population. By referring to the medical cards, which were completed during the initial clinics, the healers now have access to medical histories. The healers have been providing "mini-clinics" to the people of the villages surrounding the small town of Luperon, Dominican Republic, according to Chris Percy, VMM liaison to the Dominican Republic (verbal communication, January 2009). The efforts to promote a positive permanent change in the health care of these individuals has begun. The partnership of a university school of nursing and a medical team traveling to an underserved country to share medical information and provide basic health care made a difference to the people of the Dominican Republic. Another important aspect of this course was the effect that the experience had on the nursing students. Not only did the students gain valuable knowledge of adapting clinical experience to a different population, but they also collaborated with medical staff members to determine appropriate interventions. The education and clinic-based care provided experiential learning for the nursing students and knowledge and health care for a developing community. Our goals are not only to improve the overall health care of an extremely poor community, but to assist in ensuring the continuity of basic health care provided by their own people. This exposure to cultural diversity is necessary in today's world of health care. The students reflected, through journaling, on various topics such as teamwork, their reactions to situations in the Dominican Republic, their adaptability to many aspects of a different culture (eg, living conditions, health care conditions), their overall understanding of volunteerism, and their appreciation for American culture. Overall, this was a valuable learning experience on many levels, both personally and professionally. Margaret Mead once said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."6 Each of the students participating in the Nursing Field Studies course has experienced this to a certain degree, each feeling that he or she has had an effect on another culture, on people who were total strangers at first but who became like family. This concept is perhaps the most important lesson the students learned through this experience. It truly was much more than a college course; it was an adventure that taught that through life-long learning, one can truly effect positive change.