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Worldview 2008: A global nursing perspectiveInterprofessional, cross-cultural immersion in Nicaragua by Kathleen Nash
The interprofessional literature addresses the need for cross-professional courses to facilitate teamwork and cooperation for health care providers (Beatty, 1985; Luecht, Madsen, Taugher, & Petterson, 1990), but does not provide guidance on interprofessional cross-cultural immersion experiences. After my own experience as a volunteer nurse practitioner on an interprofessional health care mission trip, I became committed to offering this type of elective experience for nursing students. I work at The University of Texas Medical Branch (UTMB) in Galveston, Texas, USA, a health sciences campus that serves upper division and graduate nursing students, medical students and other allied health students, such as those pursuing education in physical and occupational therapy. Despite scheduling challenges, the schools of medicine and nursing at this center collaborated to offer an interprofessional elective course with a short-term cultural immersion experience in Mulukuku, Nicaragua, during the summer of 2004. This unique collaboration did not happen overnight. A faculty member in the department of family medicine at UTMB, who is a member of a church that was exploring options for a health care mission trip, made initial contact with a clinic in rural Nicaragua in 1993. The Maria Luisa Ortiz (MLO) Women’s Cooperative in Mulukuku was chosen in part because it provides ongoing services throughout the year. The purpose of the visiting teams was to augment available services and to work with the community to address its needs, not to provide quick fixes.
Since 1993, there has been an ongoing relationship among UTMB, the MLO Women’s Cooperative and the church. Dorothy Granada, a registered nurse and director of the MLO Women’s Cooperative in Mulukuku, has a faculty appointment in the Department of Family Medicine at UTMB. Although the trip is affiliated with a church, the mission of the team is to provide primary health care services, not to proselytize. The international elective course with short-term cultural immersion was first offered to medical students in 1994. Three days of didactic information on global health, health care delivery systems in Central America, water and sanitation safety, and tropical health care were followed by a two-week clinical phase. Over the years, more than 100 medical, nursing and dental students from a nearby university have traveled to Mulukuku as part of a health care team. Anecdotal evidence suggests the experience has been successful. Several students have become advocates for the underserved in their home communities, providing primary health care in underserved areas. Students report an increased understanding of cultural influences on health and a higher level of comfort working with diverse population groups (Nash, 2004).
My own experience began as a volunteer nurse practitioner (NP) and expanded to include a teaching role. It was life-changing and shaped my focus as a nursing educator. One goal for my first trip was to assess whether the international health care elective that was being offered would be appropriate and feasible for nursing students at The University of Texas Medical Branch. My experience convinced me of the importance of this type of course. I observed nursing students enhancing clinical skills, learning about a different culture, working with an interprofessional team and contributing to a nurse-run clinic. On that first trip, I accompanied a team of physicians, medical and dental students, registered nurses (including other nurse practitioners), a physician’s assistant and volunteers from the church. We flew to Managua, Nicaragua. After a 10-hour bus trip to the North Atlantic Autonomous Region, we arrived at the clinic. The Maria Luisa Ortiz Women’s Cooperative in Mulukuku demonstrates what a community can accomplish. This nurse-run clinic opened in 1990 in response to an alarming number of women dying in the countryside from complications of pregnancy or childbirth. Land was donated for the clinic, and the women’s cooperative built a carpentry shop and the clinic. Largely funded by donations to the Women’s Empowerment Network from private citizens, the clinic solicits funds through the mail, and the clinic director makes fundraising tours. In addition, charitable organizations in the United States provide financial support (Granada, 2005). The initial goal of the cooperative was to help women rest their bodies between births. However, community assessments revealed additional needs, including economic survival, personal safety, adequate housing and literacy (Gottschalk & Baker, 2004). Clinic services are tailored to those needs. Staff members also train neighborhood coordinators to identify women who want to learn to read and write, to identify homes in need of basic equipment such as latrines, to share health information and to assist women who are victims of violence. The staff includes the director, two full-time nurses, seven health promoters and a social promoter. In 2004, the clinic hired a family physician to augment its services. The health care mission teams that visit Mulukuku temporarily augment the services provided by the clinic, which records approximately 13,500 visits per year (Granada, 2005). While in Nicaragua, I learned about commitment and hard work, born of a love for the community. The women of the cooperative were at work before the sun rose. Every day, the clinic staff started early, registering the many people waiting to be seen, and staying long after nightfall, cleaning and restocking for the next day. If someone arrived after hours needing emergent care, a staff member was always available. If someone showed up hungry, food was available. If someone coming for care needed a change of clothes after walking three days in the heat, clothes were offered.
Learning from others I learned much from the people of Nicaragua. Meeting and working with the residents of Mulukuku gave me greater appreciation for their daily struggle for survival. The following example underscores for me why this kind of real-life experience is critical for learning and is more effective than classroom education. A pregnant woman I’ll call Carmelita came to the clinic in advanced labor. Her sister, a lay midwife, accompanied her. Labor was not progressing well, and Carmelita’s sister thought the visiting American medical team could help. Carmelita had received sporadic prenatal care at the clinic and was advised by clinic staff two weeks before delivery that her baby was very large, and she might need a Caesarean section. This would require travel to Managua, as there were no local facilities that could perform a surgical delivery. Carmelita had five other children at home, and her husband had abandoned her. Without money, means of transportation and someone to care for her children, travel was not an option. Carmelita elected to stay in Mulukuku. The delivery did not go well. Labor was complicated by Carmelita’s diabetes and the baby’s severe shoulder dystocia. The baby was too large to pass through the birth canal and his shoulders impeded progress. The baby was stillborn. Immediately after delivering the placenta, Carmelita began to hemorrhage. Thanks to quick action by the team’s medical director, the hemorrhage was controlled, and Carmelita’s physical condition stabilized. My deep sadness over her loss was tempered by the sense of community I witnessed. News had traveled quickly in that small community. Many family and community members came to the clinic to show their support for Carmelita and to grieve with her. As I left the clinic to try to sleep, I realized I had a lot of blood on me. I stopped by the bucket of rainwater that served as a sink. There were many people gathered in the area, and I wasn’t sure if they were family members or just concerned community members. They saw me approach the water, and a woman helped me clean up. While all were sad about Carmelita’s loss, there was also joy that she had lived. Had she stayed at home to deliver, she might have added to the statistics on maternal mortality. Carmelita’s five children needed her, and she went home to them. There was reason to be thankful. This type of experience can make a significant impact on a future health care provider. Learning about death and dying in a textbook is different from seeing it firsthand. Observing the way people in this rural community handled joy and loss offered an experiential lesson that is difficult to teach. Offering our own elective It is impossible to fully predict the results of an educational experience, and that was the case with this course. The nursing students already had experience with some clinical procedures, such as intravenous catheter insertion, Foley catheter insertion and giving injections, and they were able to help the first-year medical students learn these skills. The medical students shared their knowledge and skills from their Practice of Medicine course, which covers advanced history taking and physical examination. The students respected each other’s knowledge and were open to learning new things. While in Nicaragua, all of the students worked side by side with various providers—physicians, herbalists, midwives, and registered nurses, including nurse practitioners.
Demonstrated benefits Students who participated in the class put the experience to work for them. Most contributed poster presentations for an international on-campus conference, two submitted manuscripts to journals detailing their experiences, and several developed a research proposal based on work in Nicaragua. Some students have given community presentations about the trip, and many have volunteered in local clinics that provide care to indigent patients. In addition, many of the students have joined a university-affiliated group called Students Improving Global Health Together (SIGHT), and a few have become officers. SIGHT provides ongoing education, advocacy and service opportunities for students with an interest in international health. Through SIGHT, students have an opportunity to network with other students and faculty on campus, as well as people from other areas who have expertise in global health. Besides learning about and practicing health care in an underserved country, the students returned home determined to address marginalization whenever they see it. Many of them also participate in other volunteer opportunities with an on-campus organization called Frontera de Salud, which takes students on weekend trips to work in a primary health care clinic on the border between Texas and Mexico. They have an opportunity to practice Spanish language skills and learn about Hispanic culture and community-based clinics. The students’ participation in SIGHT, Frontera de Salud and local volunteer work with underserved people shows the importance of providing a cultural immersion experience. Their cultural competence and global awareness clearly have been facilitated by their enrollment in this interprofessional and international elective course. RNL Kathleen Nash, RN, PhD, FNP, is assistant professor in The University of Texas Medical Branch School of Nursing in Galveston, Texas, USA. References: Central Intelligence Agency. (2008, January 24). The world factbook: Nicaragua. Retrieved February 4, 2008, from https://www.cia.gov/library/publications/the-world-factbook/geos/nu.html Gottschalk, J., & Baker, S.S. (2004). Primary health care. In E.T. Anderson & J. McFarlane (Eds.), Community as partner: Theory and practice in nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Granada, D. (2002, Summer). A unique take on the Beatitudes. Granada, D. (2005, March). Extraordinary moments in Mulukuku. Luecht, R.M., Madsen, M.K., Taugher, M.P., & Petterson, B.J. (1990). Assessing professional perceptions: Design and validation of an interdisciplinary education perception scale. Journal of Allied Health, Spring, 181-189. Nash, K. (2004). [Course evaluation for international elective]. Unpublished raw data. St. Clair, A., & McKenry, L. (1999). Preparing culturally competent practitioners. Journal of Nursing Education, 38, 228-234. United Nations. (n.d.). Human development report. 2007-2008 report. Retrieved February 4, 2008, from http://hdrstats.undp.org/countries/data_sheets/cty_ds_NIC.html
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