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Keywords:

  • student experiences;
  • international clinical;
  • rotations

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES

This article explores the motivations for offering international nursing student experiences and the reasons students choose to participate. Students should prepare by learning cultural humility rather than cultural competency, and they should be oriented to the ethical responsibility implicit in caring for those in developing countries. Programs that provide these experiences need to be developed with an eye to sustainability so the lives of those receiving care will be enriched after the students go home.

Students in the health professions increasingly demand experiences in international sites as information about global health care becomes more accessible (Panosian & Coates, 2006). Dramatic increases in global migration have also contributed to the need for an international dimension to education in the health sciences, as care providers become prepared to offer culturally appropriate care to new migrants and immigrants (Koehn, 2006). The HIV/AIDS pandemic in Africa, the tuberculosis epidemic in developing countries, and increased awareness of health challenges such as obstetric fistulae have focused attention on the needs of communities beyond the borders of traditional medical and nursing educational programs in the United States (Wall, Arrowsmith, Lassey, & Danso, 2006).

As the need and desire for nursing students and faculty to be part of the solution to the health problems of developing countries increase, ethical questions are raised about the role of American students participating in health care settings abroad. Are students providing a service and gaining experience at the expense of patients who have no other choices for receiving care? At what point does the student's need for learning take precedence over the patient's right to competent care (Edwards, Piachaud, Rowson, & Miranda, 2004)? When providing care to the indigent, practice standards and guidelines for care are already in place in the United States that may not exist in developing nations or international community settings. This article discusses the ethical concerns raised by having students provide care in international settings and describes some examples of sustainable programs that have been developed with the input of the host community.

Principles of Ethics in Nursing

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES

The American Nursing Association Code of Ethics for Nurses (2001) outlines principles that address the professional behavior of the individual nurse and focuses on the overall profession of nursing. Each of these principles reflects Immanuel Kant's philosophy, as described by Day (2007): “Acting from duty [i.e., as a professional nurse] arises from a good will and therefore any actions produced will be good and right actions” (p. 179). However, this code does not address the needs of individuals within their social, cultural, economic, and political contexts when these contexts may differ from those of the nurse. Nursing behaviors that seem “good and right” in the context of the system of care in the United States may not be considered so in another culture.

An example is the use of technologic interventions to prolong the life of premature newborns immediately after delivery. Do these infants suffer unnecessarily when the customary measures of care in the United States are used in an environment in which there are no resources to continue to support them? Inasmuch as the individual nurse carries out her duty to the neonate under duress by providing care supportive of life, she is upholding her ethical responsibility. Her inability to provide for the long-term needs of the neonate presents a challenge rarely encountered in the clinical arena in the United States. The ethical issues raised by providing care in a context that is different from our own need to be considered as students venture into international settings.

The History of Nursing and Care of the Indigent

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES

The profession of nursing originally focused on addressing the needs of the underserved. Historically, hospitals were sites of care for the poor, and nursing care was usually performed by religious communities or women with limited education who may have been conscripted to alleviate their own poverty (King & Gates, 2007; Starr, 1982). The professionalization of nursing by Florence Nightingale elevated nursing beyond the menial tasks required for restoring health to those who were ill, such as bathing, bandaging, changing bedding, and feeding nutritious food to those unable to do so for themselves. The professionalization of nursing spawned the growth of organized nursing education and coincided with the development of hospitals as sites of care for both those in need, and those of means (King & Gates). The evolution of the availability of hospital care for members of all economic classes did not eliminate the continued presence of hospitals that only met the needs of the poor; in the United States, these public hospitals have become the primary sites for medical and nursing education (Anderson, Bamboulian, & Pickens, 2004).

The use of students to provide care for the underserved has met an economic need for the American health care delivery system by providing uncompensated bedside care and training. Although the patients being cared for receive a service to which they might not otherwise have had access, the care is presumptively not of an inferior quality because the students are being supervised by their licensed nurse counterparts (Bazzoli, 1986; Lyon, 2003). The association of public hospitals with academic institutions has been seen as a positive relationship. It is also considered a strength in the U.S. care delivery system because public hospitals are sites for both clinical research and postgraduate education, ensuring that care providers are well educated and possess the most current clinical knowledge. Patients who are unable to pay are able to receive care that would be unaffordable to them in the private sector, which ultimately benefits both patients and students (Anderson et al., 2004).

The Role of U.S. Nurses in Care Abroad

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES

Internationally, U.S. nurses have had a long history of participation in mission work both as volunteers and employees (Chen, 1996); this continues through such well-established organizations as CARE, Doctors Without Borders, Partners in Health, and the Global Outreach activities of the American College of Nurse-Midwives as well as many religious organizations. Although mission work is frequently associated with religious groups, it refers to any activity that is designed to transfer ideas or beliefs. The role of nurses in international health has resulted in increased opportunities for U.S. nursing students to participate in international study.

Similarly, the interest in increasing cultural awareness for students in the health professions has led to a proliferation of school-based programs that expose students to health care in other cultures. These programs may not be designed to provide students with clinical experiences that would otherwise be unavailable to them, but rather to expose students to other cultures and health care systems. To protect both patients and students, nursing programs that include international experiences need to incorporate an understanding of cultural differences and an appreciation of the complexities of global health. They must also ensure an ethical approach to care in developing countries by preparing their students for the experiences that they will encounter (Crigger, Brannigan, & Baird, 2006).

Clinical Tourism

The idea of “clinical tourism” has been described as “the phenomenon of doctors from medically advanced countries taking a ‘busman's holiday’ in the developing world” (Wall et al., 2006, p. 559). In this context, a “busman's holiday” refers to functioning in one's professional role while also vacationing or being a tourist. These seemingly humanitarian missions are a matter of some controversy because of the ethical dilemma posed about the motivations of the clinicians: are they responding to some altruistic desire to do good or are they seizing an opportunity to foster the development of new skills (Edwards et al., 2004)? When such holidays are undertaken, are they done so within the context of existing institutions, community structures, and locally identified needs? Are they merely providing exposure to another culture, or is there an opportunity for meaningful learning experiences that enhance the quality of life for both the care givers and the care recipients (Crigger et al., 2006)? It is also possible that international experiences are merely opportunities for travel with an emphasis on tourism and sightseeing.

Programs that provide health care services abroad using U.S. practitioners and students have undergone scrutiny because of the ethical need to ensure that the services that are provided are sustainable (Morgan, 2007). How valuable is it to have itinerant providers, when the kind of care that is being provided will not be continued, and no supportive care will be available? When students participate in a clinical experience abroad, are they functioning within an existing system of care that will continue after they have returned home?

The long-term consequences of “drop-in care” (i.e., care provided periodically without connection to an established health care delivery system) in the developing world must also be considered. Decamp (2007) hypothesized the following scenarios: stomach ulcers resulting from donated ibuprofen use when food and water are scarce; an unrecognized reaction to an antibiotic left by a visiting team that subsequently leads to fatal anaphylaxis; multivitamins dispensed by well-meaning health visitors that result in an overdose by children who mistake the sweet pills for candy. Misunderstanding well-intentioned health interventions is not unusual; one international visitor reports the proliferation of five-finger balloons in a community after rubber gloves were distributed to local midwives (E. Schwarting, personal communication, 2007). There is also concern that dependence on outside help supports the lack of development of local resources or encourages reliance on external sources in a way that discourages local governments to take responsibility for the needs of citizens.

The following scenario is a composite of things that can go wrong, even with the best of intentions. It combines elements of actual situations with fictional details added:

In many medical schools, it is not unusual for medical students to introduce themselves as “Doctor” during clinical rotations. In the developing world, it is very easy for students to use this appellation, since the appearance of licensed physicians in underserved settings is very rare. A young medical student, referring to himself as “Dr. Jones” arrived in a village in a Central American country during an unsupervised elective course. He greeted the villagers with bags of candies, quickly winning over the interest and affections of the children. He was able to move easily among them, taking photographs and earning their trust. He was summoned one day to the bedside of an extremely ill baby and was asked by some of the villagers to help her get better. After an exam during which he used his stethoscope and otoscope, both of which were unfamiliar to the family, Dr. Jones recognized that the child was extremely dehydrated with a high fever. Without access to the kinds of diagnostic tools—laboratory tests and radiologic examinations—on which he usually relied for information, he was unable to determine the cause of the child's illness. He told the family to give her fluids and acetominophen to keep the fever down. He was unfamiliar with the family's usual dietary habits and never inquired if the child was being breastfed or if the family had a source of potable water that would provide a suitable alternative. Unfortunately, the child died within a few days of Dr. Jones' bedside visit. The families of the village became convinced that his ministrations were the cause of the baby's death. His instruments and the medications that he gave her aroused suspicions that he may have introduced the “evil eye” or mal de ojo, a potential source of illness, or even death (Hinojosa, 2004). Because he had taken many pictures of the children in the village, others became concerned that he had used the images of the children to inflict future suffering. After the death of the child that Dr. Jones saw, subsequent visits by white American medical personnel were prohibited by the villagers, even though a need developed for immunizations when a measles epidemic swept the country.

This story identifies several elements of concern. The misrepresentation of the medical student as a qualified physician, the lack of understanding of local health beliefs, the use of unfamiliar gadgetry, and the taking of photographs without explicit permission all signal that this student identified the villagers as “other.” When students venture into other cultures, they need to understand not only differences, but also their role in overcoming those differences.

International Study to Build Cultural Humility

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES

In preparation for experiences abroad, students need to be prepared with an understanding of the clinical skills required and expectations that will be required for being visitors in another country. In addition to language skills and knowledge of health care problems and solutions abroad, students need to be equipped to interact with those from other cultures and belief systems.

The concept of cultural humility was first elaborated in 1998 by Tervalon and Murray-Garcia and has served as the basis for cultural awareness training and development for both physicians and nurses (Juarez et al., 2006). The approach of cultural humility goes beyond the concept of cultural competence to encourage individuals to identify their own biases and to acknowledge that those biases must be recognized. Cultural competency implies that one can function with a thorough knowledge of the mores and beliefs of another culture; cultural humility acknowledges that it is impossible to be adequately knowledgeable about cultures other than one's own. Another term often used when discussing working with others outside of our own culture is cultural sensitivity. Cultural humility requires us to take responsibility for our interactions with others beyond acknowledging or being sensitive to our differences.

What is required in our interactions with those from other cultures is that we approach them as equals in spite of differences in beliefs or behaviors. Furthermore, we need to recognize that we are likely to have biases about how others should behave based on our own cultural norms. When biases are acknowledged, they can be excluded from interactions with those from other cultural and ethnic backgrounds. Additionally, employing cultural humility encourages respect for prevailing beliefs and cultural norms (Jewell, 2007). This kind of respect and understanding of difference is imperative to engaging in care to individuals in multicultural settings (Crigger et al., 2006). As Crigger et al. noted: “Development of nurses as world citizens and compassionate professionals is not an inherent skill; it is an important educational component to include for students” (2006, p. 25).

Many programs exist for supporting the development of cultural humility skills; the greatest imperative is to ensure that students are availed of an opportunity to reflect on their own biases as well as learn about the cultures with which they will interact. In a safe and nonthreatening environment, students need to be able to examine their reactions to individuals who cannot communicate in the same language as their care provider, as well as reflect upon their responses to communities whose beliefs about principles as diverse as personal hygiene, death and dying, and sexual behaviors may conflict with their own. Retrospectively, students have been able to identify the value of international experiences, but their preparation for travel must also provide them with insight before their visits abroad (Kollar & Ailinger, 2002).

Materials available from the National Center for Cultural Competence at Georgetown University and the Worlds Apart series produced by Stanford University's Center for Biomedical Ethics are two excellent tools that encourage both self-reflection and exposure to diverse cultural norms. The National Center for Cultural Competence offers a Cultural Competence Health Practitioner Assessment (available at http://www11.georgetown.edu/research/gucchd/nccc/features/CCHPA.html) that enables students and faculty alike to do a self-evaluation of beliefs, practices, and knowledge of caring for individuals from different backgrounds. The Worlds Apart video series (available at http://fanlight.com/catalog/films/912_wa.php) presents four vignettes of patients from a variety of different backgrounds receiving care in typical U.S. health care settings. Viewers are exposed to well-meaning clinicians who struggle with meeting the needs of diverse patient populations and are given an opportunity for class discussion about the challenges and possible solutions for more successful patient encounters.

In addition to ensuring that students are well prepared for international student experiences, it is also imperative that educators consider creating sustainable programs that will provide underserved communities with programs and providers who can meet their needs after their visitors have gone home. Jewell (2007) described a program at Grand Valley State University (GVSU) Kirkhof College of Nursing (KCON). The KCON program involved students in Health Brigades in Miraflor, Nicaragua who provided both health care and health promotion activities. Initiated in response to Hurricane Mitch in 1998 with support from the Nicaraguan Ministry of Health, the program continues to provide U.S.-based nursing students with a cultural encounter that provides enrichment for both the students and the community (Jewell).

The KCON program was developed within the context of international development principles as well as the goals of the Nicaraguan government for responding to community needs in the wake of Hurricane Mitch. Rather than introducing students into an environment solely for the purposes of their own edification, the KCON program was responsive to the needs of a community with input from the community members. Eventually, the twice yearly visits of the Health Brigades also included students from a Nicaraguan medical school and nursing school, providing an opportunity for local entities to continue the work started by the KCON faculty (Jewell, 2007).

Another program that offers nursing students an opportunity to participate in the care of women in a Latin American country is offered to students at the University of San Francisco who travel to San Lucas Toliman, a rural Mayan community in Guatemala (Walsh, 2003). Students and faculty were invited by the local parish to provide care for community women both in their homes and at a church-owned clinic. Before participating in the Guatemalan experience, students attended seminars designed to introduce them to the community they would be visiting and to explain the complexities of the economics, politics, and social mores of the host country. Contact with the community is maintained between the semiannual student visits so that the ongoing needs of the community can be addressed, and future trips can be planned accordingly.

Project ADAMES in the Dominican Republic is another example of such a student learning experience. It provides opportunities for sustained enrichment for the providers who live there by having students participate as partners in a professional development program that is helping to increase the skills of maternity care providers in an overtaxed system. This kind of experience communicates to students that although their visit provides them with valuable skills, they are guests in other people's lives (Foster & Heath, 2007). There is an ongoing commitment to continuing the enrichment provided during the students experiences which occur two times a year overseen by a nonprofit corporation that has been developed by the program founders. The opportunity for student guests to learn is coupled with the community's need to support the existing systems of care.

Conclusion

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES

Inasmuch as nursing is a profession that possesses an ethical code, it can be argued that nurses have a moral responsibility to act in the best interests of their patients, wherever they are. Bjorklund stated: “that we have misconstrued the ethical problems of nurses by constructing them as individual ethical dilemmas existing as individual decisional conflicts within the minds of individual nurses” (2006, p. E69). The political and economic inequalities that produce health disparities abroad demand more than the response of individuals; the profession of nursing needs to provide a thoughtful, considered response that reflects both altruism and beneficence. In the process of educating nurses to become better global citizens and more competent providers of care, we need to ensure that they are well prepared for their experiences in other cultures.

Preparation for international student nursing experience needs to include an opportunity for students to reflect on their own values and beliefs about cultural difference. This is integral to developing cultural humility and greater acceptance of those from different backgrounds. Students should also be educated with as much information as possible about the communities in which they will be providing care; an understanding of the political, economic, and social conditions of their new patients is vital to their ability to contextualize both their experiences of those patients and the resources that they will utilize in the care of those patients. Finally, programs should aim to enrich the communities, which they serve beyond the immediate provision of clinical care, either by supporting existing resources, or committing to a sustainable program of services. The Chinese proverb, “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime” is just as applicable to the provision of health care as it is to food. Communities that can provide health care for themselves will be able to sustain their well-being much longer than those that rely on the occasional visits of well-meaning strangers.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. Principles of Ethics in Nursing
  4. The History of Nursing and Care of the Indigent
  5. The Role of U.S. Nurses in Care Abroad
  6. International Study to Build Cultural Humility
  7. Conclusion
  8. REFERENCES
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  • Chen, K. (1996). Missionaries and the early development of nursing in China. Nursing History Review, 4, 129-149.
  • Crigger, N. J., Brannigan, M., & Baird, M. (2006). Compassionate nursing professionals as good citizens of the world. Advances in Nursing Science, 29 (1), 15-26.
  • Day, L. (2007). Foundations of clinical ethics: Disengaged rationalism and internal goods. American Journal of Critical Care, 16 (2), 179-183.
  • Decamp, M. (2007). Scrutinizing global short-term medical outreach. Hastings Center Report, 6, 21-23.
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  • Foster, J., & Heath, A. (2007). Midwifery and the development of nursing capacity in the Dominican Republic: Caring, clinical competence, and case management. Journal of Midwifery and Women's Health, 52, 499-504.
  • Hinojosa, S. Z. (2004). Authorizing tradition: Vectors of contention in Maya highland midwifery. Social Science and Medicine, 59, 637-651.
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  • Morgan, M. (2007). Another view of “humanitarian ventures” and “fistula tourism.” International Urogynecology Journal, 18, 705-707.
  • Panosian, C., & Coates, T. J. (2006). The new medical “Missionaries”—Grooming the next generation of global health workers. New England Journal of Medicine, 354 (17), 1771-1773.
  • Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.
  • Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9 (2), 17-25.
  • Wall, L. L., Arrowsmith, S. D., Lassey, A. T., & Danso, K. (2006). Humanitarian ventures or ‘fistula tourism’?: The ethical perils of pelvic surgery in the developing world. International Journal of Urogynecology and Pelvic Floor Dysfunction, 17 (6), 559-562.
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