No Boundaries, No Barriers

No Boundaries, No Barriers

By Mat Edelson
Illustration by Ryan Etter


Refugees and workers in DRC HillsideTake a dart, throw it at a map of the world, and one thing is for certain: No matter where the tip hits, you’ll be looking at a country facing a nursing shortage. The reasons are as complex as nursing itself: Everything from natural disasters to man-made business practices plays a role. The devastating Haitian earthquake not only wiped out a country, but also in ten horrific seconds destroyed a nursing school filled with more than 100 nursing students and their teachers. That decimation of nurses was clearly an act beyond man, but that’s not the case in other parts of the world, where health ministers and administrators intentionally lure the best nursing talent away from their poorer neighboring brethren.

It’s beyond doubt that this worldwide dearth of nurses has reached a crisis point. Hearing that there are some 12 million nurses across the globe might give one pause that there’s even an issue, until the distribution is considered; it’s as uneven as the floor in a Baltimore row house. According to an International Council of Nurses (ICN) report, while the U.S. and U.K. have the lion share of nurses—roughly 1,000 nurses per 100,000 people—those ratios are vastly different in many developing areas. Chad, Gambia, Uganda…pick a country in Sub-Saharan Africa, and the numbers plummet to roughly 20 nurses for every 100,000 inhabitants. The hospital staffing in these countries is just as dismal. Wrote the ICN, “a recent report highlighted that nurse-to-patient ratios in general wards in three hospitals in Malawi were one nurse to 120 patients.”

To reverse this trend and build nursing capacity often requires entering a minefield of complicated (and sometimes corrupt) politics, economic hardships, educational deficiencies, and untold human suffering…and that’s just among the nurses themselves.

In their daily efforts to help others, nurses are exposed to disease, violence, and the frustrations that come with living in areas where the healthcare system is clearly overburdened. A Johns Hopkins due diligence report investigating a potential affiliation between Johns Hopkins Medicine International and the Kuwait Ministry of Health uncovered security issues regarding crowd control in ‘casualty’ areas of hospitals. The measured report—prepared in part by assistant professor Sharon Olsen, PhD, RN—noted rather ominously that, “As a result, exam rooms were locked during patient exams and, in some instances, an escape door was accessible if the provider was threatened.”

Even where nurse safety is assured, a rewarding career is far from guaranteed. Some nations, even fairly well-to-do ones, have trouble recruiting student nurses because the opportunity to advance educationally and assume leadership positions rarely exists. In these nations, becoming a diploma nurse is a possibility, but advancing even to a baccalaureate is unlikely.

“We need to work on that,” admits Jordan’s Dr. Ahmad Alkateib, who has partnered with Hopkins nurses to improve access to health information technology in his country. “We need to let potential nurses know where they’ll be years from now, to delineate a career path.”

Taken as a whole, the problems might seem insurmountable. And yet, in dozens of countries, progress is being made with the help of Hopkins nursing faculty. Their secret is triaging the crisis and building capacity by focusing on one locale they’ve become intimately familiar with through numerous visits over many years.

Nancy Glass in the DRC“The days of ‘helicopter research’ where you just drop in, conduct your research, collect your data and leave, never telling anyone what you found or involving the community…those days are gone,” says associate professor Nancy Glass, PhD, RN, who has created innovative capacity building partnerships in war-torn Democratic Republic of the Congo (DRC). “There’s much more emphasis on collaboration and sustainability now, and respect, engaging your foreign partners, so when a given project ends, the work won’t end.”

One could easily argue that, when it comes to capacity building, the true work is just beginning.

Building from Top to Bottom

Though South Africa is by far the richest country on the continent, ‘wealth’ is a relative term. 1994’s fall of apartheid was supposed to help spread the country’s resources—including access to healthcare—among all its peoples. Yet nearly two decades later South Africa struggles to keep enough nurses to meet demand. Nurse migration—the term used for nurses who take their education and seek better employment opportunities abroad—has taken a huge toll on the country; a U.N. report estimated it cost nearly $184,000 to replace each nurse leaving South Africa, a situation so dire that the South African Nursing Council considered taxing foreign employers who went after their nurses.

Slowing that drain means attracting additional resources, such as professor Phyllis Sharps, PhD, RN, and her students, who have visited South Africa to assist the nation’s few nursing PhDs with their research. Sharps says providing Hopkins student volunteer manpower and faculty training in epidemiological rigor is vital: Funders—both private and governmental—are becoming more demanding about the kind of health projects they’re supporting.

“Anecdotes are nice, but in today’s world, people are looking for evidence,” says Sharps. “They want to fund projects that have the best science and the best people prepared to implement something new. That’s often PhDs who can identify the needs, have a solution based on science, and the ability to implement the solution to get the intended results. Also, making policy, suggesting protocols…those things have to be evidence-based.”

Sharps’ goal is to build South African nursing capacity from the top down, creating a research infrastructure that attracts nurses willing to educate new students as their own careers climb the PhD ladder. But once those students get out in the field, it’s people such as assistant professor Jason Farley, PhD, RN, who are intent on keeping them healthy in the workplace.

That’s not a given in South Africa, where HIV and TB often run wild. “In some provinces in South Africa, the prevalence of HIV among nurses and healthcare workers is as high as twenty-five percent. There is also extremely high co-infection of HIV and TB among those workers. They’re putting themselves at risk just by working,” says Farley, who has spent a decade visiting the northeastern province of KwaZulu-Natal.

Jason Farley in KwaZulu-Natal, South Africa

Farley’s infection reduction effort is literally based on word of mouth. TB is often spread from patient to nurse via conversation. Since a common side effect of TB drugs is hearing loss, Farley’s research showed that nurses often remove their protective facemasks when talking with infected patients. “They would say, ‘a patient has to read my lips, or be able to hear me better, and they can’t do that if I’m wearing that mask,’” says Farley. “And so they would expose themselves to potentially drug resistant forms of TB.”

Farley realized nurses hadn’t been educated regarding when and where a mask-less conversation could safely occur. “Outside, there’s natural ventilation to disperse the germs. Sunlight kills TB. You can talk as loud as you like,” says Farley, who has been urging nurses to take ambulatory TB patients away from germ-filled wards to discuss their situation. “There’s lots of reasons why one would have the conversation outside.”

What Phyllis Sharps and Jason Farley share is an informed understanding of how healthcare works in South Africa, not in theory, but from years of first-hand experience. Perhaps not surprisingly, they’ve observed other holes in the system, places their expertise can make an impact.

While Sharps has helped promote the use of a nursing specialty new to South Africa—forensic nurses—in Cape Town domestic violence shelters (those nurses help women gather physical evidence that they’re abuse victims), Farley is expanding his infection control work. One difficulty in building capacity is that, until recently, South African field nurses were not allowed to start care and manage HIV or TB infected patients. That burden fell on rarely-seen doctors, leaving many patients underserved. Through research and lobbying, the South African health ministry is slowly changing its position to allow nurses more autonomy. As part of that, Farley is training a cadre of field nurses to manage HIV and TB infection care. “We’ll look at patient outcomes, adherence to therapy, mortality…really focusing in on improving care and improving access to care.”

Not to mention giving nurses the tools they need to keep both their patients and themselves healthier.

Creating Connectivity

To Patricia Abbott, PhD, RN, being wired isn’t the same as being connected. Many nations feel that linking into the digital age is essential to establishing an effective nursing infrastructure. As an Information and Communications and Technology (ICT) specialist, Abbott knows they’re right, but she’s also seen administrators of national health systems frustrated time and again. They don’t understand that plugging in a monitor or buying a software package is just the beginning of the ICT conversation.

“The United Arab Emirates have spent millions and millions of dollars on information and communication technology, but they don’t have anyone who is educated to program it and make it work.” says Abbott. “So they buy it and it sits on a shelf.”

For nurses, accessing programs and portals custom fit to their needs is key to coordinating care, improving patient outcomes, and, in a very real sense, career satisfaction. What Abbott and her students are doing is asking nurses around the world: What can ICT do for you?

The answers come quickly, especially from young nurses who are, as Abbott likes to call them, ‘digital natives.’ Many are students in her classes, eager to learn about capacity building issues they can address through computer-based solutions. Helen Baker ’10, worked with several other students to provide Haitian nurses with much-needed peri-natal information. “We made a narrated PowerPoint presentation on post-partum depression, something that’s not readily available in French. Three other students and I… were all in African French-speaking countries when we were in Peace Corps service…so we wrote and recorded it in French.”

Hopkins nursing student providing care in HaitiBaker was able to post the presentation on the Global Alliance for Nursing and Midwifery (GANM) electronic mailing list. Abbott established GANM in 2005 as a worldwide ‘electronic community of practice,’ much of it evidenced-based. The ability of the portal to sustain capacity was clear in the days following the Haitian earthquake, when desperate Port Au Prince nurses were able to access UN internet lines, and put out a call for help. Their medical library had been decimated, and they were frantic for disaster-related protocols.

Abbott posted their plea on the GANM e-list, and the worldwide response from fellow nurses was overwhelming. “They provided electronic resources, coming in French and Creole: ‘How to care for open wounds without water,’ ‘How to deliver babies without a birth kit.’ My students collected this and created a digital library, jammed it onto two USB flash drives, and shipped them down to Haiti through the U.N.,” says Abbott. “We also put the library on Hopkins J-share (an open file-sharing website) for those Haitian nurses who couldn’t get to the flash drives. It was one of the most humbling and rewarding things I’ve done as a nurse.”

Creating permanent digital libraries is one way to augment countries creating a sustainable nursing infrastructure. Another is helping nurses design and use software to address weaknesses in their practice. Jordan’s Ahmad Alkateib, who began his career as a nurse, is consulting with Abbott about creating permanent electronic medical records for patients. Right now, patients are expected to bring their records physically with them between appointments and locations, often resulting in lost files and impaired care. “Say it’s an emergency, the patient has an allergy, and the ER staff doesn’t know this,” says Alkateib. “If they had access to his records on the computer, they could avoid an error and maybe save a life.”

Whether it’s helping countries reduce medical mistakes or better track the whereabouts of their graduate nurses to increase retention rates, Abbott sees ICT as a key player in addressing capacity issues. She sums it up with what she calls her mantra:

“You can’t manage what you can’t measure.”

Ensuring Sustainability

Sometimes a country takes you into its heart, and never lets you go. As a 21-year-old Peace Corps volunteer, the beauty of the Democratic Republic of the Congo (DRC) and the struggles of its people changed Nancy Glass’s worldview forever. Over the ensuing years, she’s visited the land again and again, even as it descended into a horrific civil war that still rages after more than a decade, leaving DRC’s citizens among the poorest in the world.

Hopkins nursing studentsWithin that poverty and violence, Glass, PhD, RN, has expanded her definition of what it means to build capacity. Yes, she still goes the conventional route—her work in well-organized and politically stable Uganda is funded by the Gates Foundation and aimed at raising the influence of Makerere University’s nursing program by turning research findings into health policy changes—but in decimated DRC, basic survival is still not a given.

In such dire straits, the notion of creating sustainability, of nurturing a workforce, takes on a far different meaning. DRC suffers from perhaps the world’s highest rate of rape. While that’s fairly well known, what isn’t talked about—or treated—is the increasing number of men who are raped. The stigma and trauma associated with rape have made many men—including healthcare workers—outcasts.

Glass and some of her students are attempting to systematically research and shed light on the issue. “Some people say male rapes aren’t happening and that it isn’t a problem. We’re getting reports on the ground saying it is. So we take an integrated approach: Define the problem, raise awareness among funders and healthcare workers, develop interventions to treat victims, and get them back to their lives. That’s their focus, to get back to work and live life like it was prior to the war.”

Part of that is actually having an economy with which to work. While she raises funds and personally volunteers her time providing free care to families in rural clinics, operating out of looted buildings that her partners have rehabbed and restaffed, she knows those efforts are temporary band-aids. The permanent solutions involve economic development. And though that’s not usually the province of nurses, Glass is an exception. She began “Pigs for Peace” a few years ago, the idea being that women could raise their entire community’s standard of living by raising and breeding donated piglets, and giving two back from each litter to the organization to begin the process again with another family.

The initial stock of 11 pigs has bred success: Now, 226 families in 14 villages are raising pigs. “It’s a start,” says Glass, “a way to develop household economic stability, helps them buy food, put kids back in school.”

And maybe, one day, grow up to be nurses.

Working Together

From Sara Groves, DrPH, RN, who is building fledgling graduate nursing programs in Uganda, to Miyong Kim, PhD, RN, who is training healthcare workers along the Korean-China border, Hopkins nursing faculty are building capacity with a global scope.

Sara Groves at the Makerere College of Health Science in UgandaBut to be sustainable, a greater coordination of initiatives may be necessary, perhaps reaching to other American nursing schools conducting their own capacity outreach. “The connectivity between institutions (sending faculty abroad) is often missing,” notes David Benton, Swiss-based CEO of the International Council of Nurses. Benton says the real concern is foreign health ministers declining nursing assistance because of the mixed messages they receive from different consulting faculty. “If you say something to me and another person says something different, at best I’m confused and frustrated, and I’m likely instead to go do my own thing.”

Still, seen as a continuum, many faculty are encouraged about the deepening of their relationships with their foreign counterparts. The more they understand a country’s needs, the better they are setting their own pre-conceived ideas aside, putting their academic egos on the back burner, and providing the services that their hosts truly need.

When Jason Farley first heard of South Africa’s TB crisis, his initial reaction was to get nurses quickly trained and right out into the field to fully manage cases, something they hadn’t previously done. The Health Ministry hesitated, suggesting instead that Farley work on a more focused problem, the fact that patients were quitting TB therapy because of side effects. Farley adjusted his research, adding that the success of the symptom management program he designed lead to greater confidence on the part of the ministry to utilize his suggestions. That eventually helped shift the entire country’s approach to treating TB, with nurses taking on a far greater role which may greatly improve outcomes.

And that, says Farley, is what building capacity is all about, leaving countries in a position to both evaluate and implement programs that best utilize their nurses. “Because I come at it from the viewpoint that it’s about the community’s input—the researcher comes up with the idea, but the target of that research really gives and takes and decides whether or not those ideas will meet their needs—the trust really grows significantly,” he says.

“It’s not about what Jason Farley or Johns Hopkins wants. The huge nursing aspect of this is, it’s not simply about how many publications you provide, but how many lives you save ultimately in the end, working with the communities you’re involved with.”

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