Building Sustainable International Nursing Collaborations

The history of medical missions’ dates back to the 18th century when an American missionary to China, E.C. Bridgman, noticed that Western medicine was more effective than Chinese medicine in curing cataracts. Since then, there have been countless health missions sponsored by faith-based and humanitarian groups to all parts of the world to reduce suffering and improve the quality of lives of vulnerable populations [1]. Africa has been a major recipient of such aid due to Africa’s poor health statistics: Africa ranks low on most of the indicators of sustainable development goals [2]. This is due mainly to poor health policies, poor funding of health care, marginalization, and political/civil unrest. Effective health missions involve reaching out to the poorest and most vulnerable populations by providing curative and preventive treatment in a sustainable manner. This involves empowering all stakeholders to sustain a culture of healthy living by providing them with information in a culturally sensitive manner and the tools with which to accomplish this. To achieve this, effective health missions to Africa have applied a partnership model that builds on the strengths of every stakeholder, promotes synergistic relationships based on trust, and provides opportunities for learning from one another. Health missions to Africa have been effective in combating endemic illnesses such as malaria and global health challenges such as HIV/AIDS due to their ability to combat the social roots of ill health and address the social determinants of health.

Sponsoring organization

Global health experts refer to surgery as the “neglected stepchild of global health.” Shortterm surgical missions to the developing world are a widespread effort that attempts to fill this void in surgical capacity [3]. operation rainbow and save-a-limb are two non-profit organizations that sponsored our nursing mission to black lion hospital in Addis Ababa, Ethiopia. operation rainbow began in 1978 when a plastic surgeon from Texas witnessed the unmet need of cleft palate repair in the Philippines. in 1990 the organization realigned its focus to pediatric orthopedics, another unmet need in developing countries. the organization sends ten surgical teams a year worldwide. along with orthopedic surgery, they train local doctors, nurses and staff to enhance their capacity to care for their own populations. in four decades, operation rainbow has performed more than 17,000 surgeries in 22 countries. our second sponsor, the save-a-limb fund is associated with Sinai hospital in baltimore, Maryland. save-a-limb supports pediatric orthopedic missions to impoverished areas around the world. they provide supplies, medications, skilled orthopedic treatments, nursing care, and education. the fund also provides resources for one international patient per year to travel to Sinai hospital for treatment.

Objective

The purpose of our mission was to conduct a limb deformity workshop for 40 local surgeons and a nursing workshop for 23 local nurses. This was the first international training session for the local nurses at Black Lion Hospital. The nursing education component of this mission was to empower the local nurses with evidence-based practice in order to improve health outcomes at their own hospital.g. Laparoscopic procedures during pregnancy carries the following potential concerns:

Planning

Prior to arrival many email exchanges took place between the head nurse at the pediatric orthopedic hospital, cure and the public hospital, black lion. together a syllabus was created to prioritize the local needs. poor internet service created a barrier to the free flow of ideas; however, a few months prior to arrival, the syllabus was edited and approved by the local head nurses. our team members arrived in Addis Ababa from four countries: the united states, Austria, Israeli, and Nigeria. many of us met for the first time; others had worked together on past missions. our nursing specialties included operating room, post-anesthesia care, public health and a nurse educator. the diversity of our team offered a broad range of topics and experiences that promoted an open dialogue between our team and the local nurses.

Program

Both four-day workshops included surgeons and nurses from Black Lion Hospital (public hospital) and Cure Hospital (private hospital). The nursing workshop included a broad list of topics, including Preventing Road Traffic Accidents, Pain Management in Children, Medication Safety, Workplace Safety, Roles and Responsibilities of the OR RN, Roles and Responsibilities of the PACU RN, Crucial Conversations, Empowerment and Effective Teams, Infection Prevention, Diabetes-Stroke-Breast Cancer Awareness, and CPR review. Healthcare workers across various disciplines from both the Black Lion Hospital and Cure Hospital participated in the weeklong training session. The participants included nurses from the perioperative setting-ranging from the Pre-op arena, intra-op OR theatres, and those who render postsurgical recovery care-as well as representatives from pharmacy and other medical-surgical floors. The degree of clinical experience among the participants ranged from a minimum of one year of hospital experience to seasoned healthcare workers who have been in the medical field for over 10years. This mix provided an avenue for a shared interactive learning experience.

The first day of the nursing workshop kicked off with sessions on team dynamics and effective team interactions, which included topics on cultural sensitivity, diversity and inclusivity, managing crucial conversations, empowerment, ethics, and moral reasoning. The succeeding days addressed nursing basics, which included, among others, topics pain management in children, medication safety, workplace safety, infection prevention and control, postural hypotension, stroke, diabetes and breast cancer awareness. To create an interactive atmosphere suited for adult learning, demonstrations and return demonstrations were employed as learning strategies especially on topics involving proper hand washing and the preparation of alcohol-based hand rubs. Since a majority of the participants were from the intraoperative arena, the discussions also included the principles of asepsis, operating room basics, roles and responsibilities of a circulating and scrub nurse, principles of time-out and debriefing, surgical positioning and surgical skin antisepsis. The participants were very interested to know how the practice of the OR setting in the west differs from what they do in their own practice environment.

The discussions focused on what the participants can take back to their respective practice settings to improve the delivery of care without jeopardizing patient safety side-by-side with the reality of the availability of resources in their own respective institution. One of the most relevant discussion topics was on preventing road traffic accidents. This proved to be quite timely: A day after the lecture, a fatal traffic accident occurred right in front of the hotel where the speakers were staying. We observed firsthand the real-life scenario that unfolds when a real road accident occurs in the streets of Addis Ababa. To witness such a horrific situation was not just gutwrenching but also brought out a life-saving opportunity of having to present a training session on emergency medical management that would emphasize damage control brought about by massive bleeding and similar life-threatening consequences.

Finally, the last day of the training was dedicated to cardiopulmonary resuscitation and basic life support. The speakers divided the group into small teams that took turns in demonstrating the skills and principles taught on basic life support and CPR. The participants had the chance to demonstrate their newly acquired skills using both adult and pediatric mannequins. In addition, the basic management of airway maintenance was emphasized in addition to teaching concepts on prevention and emergency intervention for choking. To cap the weeklong activity, the participants were awarded certificates of completion. Participants in the educational program completed an evaluation survey. The overall feedback on the educational program was positive.

Stop the bleed

The following is a description of the road traffic accident witnessed by two team members. I heard a loud crash and swiftly went outside to the balcony. I hesitated to respond to the crash due to the class discussion on the previous day. One instructor pointed out that in parts of Africa some people face imprisonment for responding to an auto crash. I saw multiple members of the community respond to the accident immediately. I was impressed by the community commitment to help the victims, but also distressed when one of the victims was pulled from the van and bled out in the middle of the road. No one made any attempt to reduce the bleeding. The man appeared to be unconscious and within a couple of minutes the blood pooled around his body. This incident reminded me how basic first aid knowledge saves lives. The bystander’s motivation to help was clearly present but the knowledge of how to increase the victim’s survival was missing. I felt our team had a moral obligation to help in a way that would enable the community to appropriately stop the bleeding of future traffic accident victims. A second team member gave her perception of the crash.

On the second day of our mission, a few members of our team witnessed a road traffic accident in front of our hotel. Two vans carrying approximately nine passengers each crashed at an intersection. The collision caused one van to roll on its side. After five minutes without an ambulance arriving, two team members offered their assistance. At the scene a group of bystanders used their hands and collective strength to turn the van upright and get the people out. A thick line of blood could be seen from the point of impact to where the van came to a halt. Within fifteen minutes, most of the injured were picked up by passing motorcycles or private cars and taken away. When the police arrived, they quickly began clubbing people who were too close to the van. We later found out they were trying to prevent looters from picking over the personal belongings of the accident victims. After twenty minutes, an ambulance did arrive but by that time only one unharmed victim remained at the scene. When our team arrived at the hospital the next day, we were informed that one person died in the accident and another was in emergency surgery. After witnessing the accident firsthand and noting the extended amount of time it took for an ambulance to arrive, our team discussed the feasibility of implementing a Stop the Bleed program in Addis Ababa.

The next day our team and the local nurses discussed their perception relating to road traffic accidents in Addis Ababa. The local nurses explained that the general community response is to call an ambulance or the police when there is an accident. If the victims are not severely injured, a bystander may transport them to the closest hospital, or they can wait for an ambulance to arrive. Reasons for delayed transport include, lack of ambulances in certain district regions, lack of communication between the victim and the receiving hospital and poor road conditions. In Ethiopia it is culturally acceptable for the family and those who witness the accident to transport the victim in their personal automobile or send the victims by taxi to the nearest hospital.

One Ethiopian nurse shared a personal experience. I lost my father as a result of a road traffic accident a few months ago. He faced many difficulties. My father was alone at the time of the accident, but the people around helped him. They called my brother and then took my father to the closest clinic. My father was unconscious and needed better medical management. We found an ambulance to take him to the governmental hospital, but the police officers at the scene spent too much time on the paperwork and punishing the one at fault for the accident rather that helping the victim. Because of the police, the quality of the treatment for our father was reduced. They also pushed us to take him to the governmental hospital because they would accept the police documentation. However, our government hospitals are so busy and have limited resources. The doctors failed to diagnose my father in time. We spent a long two days in the emergency department with my father being treated with pain medications while lying on a stretcher waiting for a diagnosis.

After he was diagnosed, they decided to do brain surgery, but the surgery was delayed due to a lack of resources. While waiting for surgery, my father was started on IV medication in the ward. Every day my father’s condition worsened. He died waiting for surgery. I saw a knowledge gap in the police officers. They did not know how to prioritize the medical condition over the crime scene. I saw a knowledge gap in the drivers. They also needed training on first aid and how to sustain human life. I saw a lack of materials in the hospitals and, to be honest with you, a lack of professionalism in the medical personnel.

We began by establishing a supportive relationship based on common values with the Ethiopian nurses during the nurse education course conducted in 2018. Our team began our first educational activity in Ethiopia with the nurses by discussing values, ethics, and cultural humility. Cultural humility is the ongoing practice of listening and giving value to voices other than ourselves. We facilitated discussion around skill sets to hold crucial conversations and the importance of nurses using their voice to advocate for patients. Our lecture content described healthcare responses to motor vehicle accidents within Africa and the need for change. Through developing relationships with the Ethiopian nurses, we learned that our teaching team members and the healthcare team in Ethiopia shared a concern and passion for the victims of motor vehicle accidents. The proposed follow-up project serves as a method to both educate and empower Ethiopian nurses to act aimed to improve the mortality rate for victims of traffic accidents in the surrounding communities.

Connect on values

The International Council of Nurses (ICN) Code of Ethics for Nurses is built upon the overarching concept that nurses’ practice within relationships [4]. These relationships include patients, their families, and interprofessional teams. Snellman [5] described six core values in the international nursing literature: trust, sympathy, support, knowledge, and responsibility. The six core values are shared within the international community. We propose that any follow-up intervention in Ethiopia should be based on these six international nursing values and promote a culture of ethical practice. A team standing together based on shared values can be a powerful force. A culture of ethical practice can be defined as a practice composed of values, norms, systems, and structures that support moral agency, moral resiliency, integrity, and dignity [6]. The United States and Ethiopian nurses can relate to feeling responsible to act when someone has a life-threatening condition. Beneficence, doing good and not harm to patients, is a characteristic that is shared within the healthcare profession. Based on our observations of the traffic accident response, the community sought to “do good” and prevent further harm to the victims. Doing good and helping others is a core value that can unite both the international healthcare teams and the Ethiopian community. This value of responsibility to “do good” can be a powerful motivation for community action.

Stop the bleed training

The rate of intended and natural disasters has been increasing globally, and Africa is not left out [5]. The death rate from intentional injury in Africa is estimated to be as high as 60.9deaths per 100,000 people [6], with “morbidity and disability from intentional violence exceeding this value by as much as 20times” [7,8]. The burden of intentional injuries is higher in low-to-middle-income countries than in developed nations. One of the immediate physical effects of an injury is bleeding. If prompt care is not immediately provided, uncontrolled bleeding could result in death in as little as five minutes [9]. The study by Yeboah et al. [10] revealed that bleeding following a traumatic event is the leading cause of definitely preventable deaths in Ghana. Emergencies resulting in bleeding could occur anywhere, at any time, and to anyone; hence, there is a need for individuals and communities to be empowered to effectively stop bleeding [8]. Studies have proven that the actions of lay bystanders to halt bleeding immediately following an injury, saves lives [11,12].

Stop the Bleed is a national awareness campaign to encourage bystanders to help with bleeding emergencies. Stop the Bleed was initiated in April 2013, a few months after an active shooter killed 20children at Sandy Hook Elementary School in Newtown, CT. It was a collaborative effort between the American College of Surgeons, the medical community, the federal government and other organizations. The committee created a national policy to enhance survivability from an active shooter and intentional mass casualty events [13]. The Stop the Bleed Program was launched in “October 2015 in the United States with the intention to cultivate grassroots efforts that encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives [9]. With the proper tools, training, and empowerment many lives can be saved [9].

The acronym “STOP” stands for: “Search for patients at risk of bleeding, treat bleeding as soon as they develop, Observe the response to interventions, and Prevent secondary bleeding” [6]. This program has been effectively used in Kuwait [14], and in rural and urban areas all over the United States [9,15,16]. School children, military men, grandmothers, teachers, retail workers, and all members of the public, irrespective of their educational and financial status, have been successfully empowered to save lives through this program [9,11,12,15,16]. Despite the availability of numerous studies on the effectiveness of correct bystander intervention in halting bleeding and saving lives after an injury, [9,11,12] many people are still uninformed [11].

Though highly effective, [9,11,12,15-17] the Stop the Bleed campaign has not been deployed on the African continent. The BleedingControl.org website provides instructors and the public with training and materials free of charge. Studies have shown that the help given by an immediate responder can often make the difference between life and death, even before professional rescuers arrive. The Bleeding Control Basic Course provides participants with the necessary tools to become empowered immediate responders. Since its inception, 500,000 people have been trained in 90countries and in all US states.

Develop a sustainment plan in partnership with the Ethiopian team

To empower the Ethiopian nurses, there should be a sense of ownership. The United States-based team desires to coach and support the Ethiopian team in developing the Stop the Bleed Program for Ethiopia. A more consistent mode of interaction is needed to develop rapport, trust, and a transfer of knowledge. In the future we hope to use video conferencing with the local nurses to help build more leaders and educators.

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