Global nursing, in its many forms, is about ensuring that a big world with lots of health issues heals evenly.
Is global nursing sending students halfway across the world for a brief, intense lesson in screening and education of local populations? Or is it helping to establish the first nursing PhD program in China or the first doctor of nursing practice education in Saudi Arabia, something the Johns Hopkins School of Nursing had key roles in? Is it walking out the door of the school in East Baltimore and heading into the community for a home visit? Or is it working with local aid groups to ensure the safety of women in war-torn nations?
Yes, yes, yes, and yes. Because what happens today across the globe happens tomorrow in East Baltimore, or wherever you happen to be reading this. And so the global nurse researchers of Johns Hopkins have heard the dismissal of travel to needy areas as “voluntourism” (a play on volunteerism). But they know better, with an understanding of how profound an impact these journeys, done properly, can have.
Associate Dean Nancy Reynolds, PhD, RN, C-NP, FAAN, has been part of health missions to rural China, urban India, and Russia, among other spots. She has seen the need. “Health problems are increasingly the same throughout the world. Urbanization, migration, aging of the world population, fragmented health care systems, human workforce shortages, and the increasing prevalence of chronic diseases such as diabetes and heart disease are among trends creating unprecedented health challenges globally,” Reynolds explains. “Nurses are the largest cadre of the global health workforce. They offer a vast resource.”
And she feels that those from the most advanced societies can have the biggest impact. But again, do it right. “We are careful in how we approach that … that we don’t undermine local services by accident. There’s an evaluation on both sides to be sure of mutually beneficial outcomes and true partnerships.”
The physical presence of Johns Hopkins nurses in far-flung locations—even on short visits—is crucial for building rapport and confidence among those who work there every day, adds Professor Nancy Glass, PhD, MPH, RN, FAAN, whose travel includes regular stops in war-torn nations in Africa. “There is the respect and trust of your colleagues—that they know this is important enough to you that you are taking a risk to do it. That you really value what they do, because the work they are doing on the ground is really challenging. It’s key to be there to support them.”
And always, she says, visiting researchers must be subtle: “It is their home, not ours.”
‘Interconnected Systems’
Part of her role is simply to listen, explains Glass, associate director of the Johns Hopkins Center for Global Health and an expert on preventing violence against women and children. “We foster community-level discussions on societal norms.” Then, “We work to change the norms that support gender inequity.”
Local health workers receive education in data collection and how to ask sensitive questions, mentoring throughout the process, and assistance with evaluating the data collected. So teams eventually become more self-sustaining.
Adds Reynolds, “Nurses can help fill a critical need for the education and training of health care workers, in the development of innovative, practical solutions to common health problems and by informing and advancing health policies within and across borders. Ultimately, with adequate resources and preparation, nurses have the potential to make a critical difference in the lives of people throughout the world.”
And the world needs researchers who have been there before, says Associate Professor Jason Farley, PhD, MPH, ANP-BC, FAAN, who works to prevent HIV and tuberculosis coinfection in South Africa and the United States. “Humans receive care in complex, interconnected systems,” explains Farley, president of the Association of Nurses in AIDS Care. “Exploring health systems and opportunities to strengthen those systems requires a fundamental expertise in system design and methodological considerations for improvements. In South Africa, I—along with a team of doctoral students—am working to improve treatment outcomes for patients with drug-resistant forms of TB simply by optimizing the role nurses play in the complex model of care.”
Those doctoral students may one day become the next generation of global health leaders.
‘Common Understanding’
Assistant Professor Carmen Alvarez, PhD, RN, CRNP, CNM, recalls her time as a student looking at controversial HIV care methods in Cuba and how she was struck by how health care in general takes place on the island—long cut off by a U.S.-imposed embargo from much of the world. “In Cuba, physicians and nurses are part of the community. They live there. The community health clinic is there. There is a common understanding.”
In the U.S., conversely, “Those of us who work in community health clinics, we don’t often live there,” explains Alvarez, who works with trauma survivors and underserved women with chronic diseases. “So we must be conscious of our assumptions [about patients], maybe take a step back to retain our cultural humility. We need to really listen to get a feel for their needs.”
She adds that even as we offer our knowledge and expertise on other shores, there is much that we can learn and bring home.
And about the HIV care in Cuba: Back then, new patients were forced into a sanitorium for extensive education on the disease and how it’s spread. Anti-retroviral drugs and care were free, families could visit, and employers could not fire the HIV-positive. With the stigma removed, the idea was, HIV/AIDS could be addressed openly. The fairness of the program (now voluntary) has long been debated, but Cuba continues to trumpet its success.
Johns Hopkins nursing students have made similar missions to Guatemala, St. Croix, and Haiti, and the school’s returned Peace Corps volunteers have served everywhere on the globe, “exotic” and not. Pictures shared on social media—and in this magazine—tend to show adventures outside the clinic. This is partly because students are drilled in patient privacy and partly because there is little time to take snapshots during clinical hours.
The off-duty fun is real, but so are the hard work and the results, Reynolds insists—for the local populations as well as the caregivers who are being groomed as the best listeners, innovators, healers, and nursing leaders on the globe.
A SENSE OF PLACE
By Steve St. Angelo
Experiencing worlds we might never step foot in—through the vivid memories of Johns Hopkins Nursing researchers
We can share the stories of healing breakthroughs that change lives everywhere Johns Hopkins School of Nursing researchers go. Yet most of us will never walk where they’ve walked or see what they’ve seen. So global researchers offered to let us live vicariously through their memories of what it feels like, looks like, smells like, to be there, even if there is right here in the United States.
What follows is a peek, or a sniff, at their worlds from Nancy Glass, PhD, MPH, RN, FAAN, Teresa Brockie, PhD, RN, FAAN, Nancy Reynolds, PhD, RN, C-NP, FAAN, and Amanda Coyle, PhD, RN, FNP-BC.
A Safe Distance
Charcoal is the common ingredient to cooking, heating, and family gatherings around the hearth at day’s end in Somalia. It is the smell of calm, of peace, the scent that greets Nancy Glass at the Mogadishu airport as she begins another mission to help those trapped in a cycle of war and violence.
There is a palpable sense of danger to each trip, but Glass says her greatest fear is putting those around her in peril. To associate with an outsider, an American, on social issues unpopular with violent groups can be a death sentence.
Glass, a tall Caucasian with piercing blue eyes, does not blend readily in the parts of Africa she feels called to serve. Often, Glass admits, she overcompensates, covering herself (according to the Muslim nation’s custom for women)—but with a clumsy amount of cloth. During one trip collaborating with the United Nations International Children’s Emergency Fund (UNICEF), local colleagues teased Glass about covering up so completely. “Al-shabaab is not here,” they reassured her, a reference to one of several Islamic insurgent groups in Somalia and the surrounding region that use rape, kidnapping, and mass killings to mark what they claim as their territory.
Some months later, during a phone call, Glass learned that many of those same UNICEF colleagues were dead, their van destroyed by a bomb.
Mostly, Glass conducts her business at the Mogadishu airport, quick in and quick out so those who might be watching do not pick up a pattern and, again, so her colleagues are not put in jeopardy. Nonetheless, Glass feels her missions have been fruitful. Her research, insight, empathy, and educational and policymaking skills help people she will never be allowed to physically touch, at least while the current violence rages. It is a tradeoff she accepts with sadness but determination. And she will be back.
Love & Prayer
Teresa Brockie pulls a small woven basket from a shelf, gently stirs the sage within it, and talks of Fort Belknap, MT.
A member of the White Clay (A’aninin) Nation, Brockie uses the herb as part of her daily smudging, a centering moment meant to “cleanse the body, mind, and spirit to prepare you to speak to the Creator.” As such, smudging is traditionally done before a tribal ceremony, she explains. The herbs, woven in three-strand braids, are often given as gifts.
When travels do take her to Montana, Brockie looks forward to the wild sweetgrass, sage, and cedar of a place that provides her spirit sustenance. The scent of the burned herbs awakens memories. “I pray for the people who aren’t around anymore,” she explains. “I think of my grandmother … her face, how soft her skin was.” And she knows she is home.
Smudging also plays a large part in Brockie’s work on other reservations across the American West, where trust earned among tribal elders carries great weight with the families she hopes to collaborate with to address distress. (Her research focuses on childhood traumas that can lead to depression, substance abuse, and in some cases suicidal thoughts among tribal populations.)
“Tribal identity is tied to the places, the language, the spirituality, the land. It’s where my ancestors and my grandmother are buried.”
—Teresa Brockie
Back in Baltimore, Brockie relies on a supply of herbs (mostly sage) from family members still in Montana, “picked with love and lots of prayer, braided with love and lots of prayer.”
She hopes she has enough to last the winter. “I miss that I don’t have access to it,” she says. “Tribal identity is tied to the places, the language, the spirituality, the land. It’s where my ancestors and my grandmother are buried. … I miss Fort Belknap so much.”‘Generosity of Spirit’
Ask Nancy Reynolds how she knows she’s back in China, a nation she visited often as faculty at Yale University and with which maintains a strong connection, and her eyes light up: “Just the vitality and sense of optimism in the country that’s exciting. And the friendliness,” explains Reynolds, whose global research focuses on HIV, mental health, and self-care behaviors among vulnerable populations. “It’s like, ‘This is so nice.’ ”
It’s a country she grew to love, and how could she not? “The first time I went to China was as part of a delegation, and when we arrived … it was 20 people there meeting us with flowers and there’s just this warmth, and a breathtaking generosity of spirit.”
Reynolds is a National Institutes of Health consultant, served as a trustee of the Yale-China Association, as a member of the Yale Global Health Initiative Advisory Committee and as interim director of that school’s global initiatives, and as a mentor to nurse and physician fellows in India, Ghana, Thailand, the United Kingdom, and Uganda, as well as Russia and China.
“When I’ve gone to China—and this is true with any country, really—it’s like peeling back layers of understanding.”
—Nancy Reynolds“When I’ve gone to China—and this is true with any country, really—it’s like peeling back layers of understanding. You sort of think you have an understanding of a country and each time you appreciate different aspects in more depth. I feel like I’m still just sort of scraping the surface.”Beauty in a Time of Ebola
It was a lovely night in Sierra Leone, and all around Amanda Coyle, people were fighting for life. “The setting is incongruous—golden evening light, the hint of a breeze, a rare cool evening; peaceful almost. And yet we are rounding in our alien-looking space suits, checking on patients, treating what symptoms we could with medications … mentally accounting for patients in three categories: improving, worsening, dead.”
It would be a typical evening at an Ebola unit for Coyle and other workers who had followed the nearly two dozen steps involved in donning personal protective equipment and then armed themselves “with blankets, water, clothing, medication, sometimes little toys; anything we could fit in our arms.”
“We are rounding in our alien-looking space suits … mentally accounting for patients in three categories: improving, worsening, dead.”
–Amanda CoyleCoyle, a family nurse practitioner, had signed up for the work out of a sense of duty, leaving family behind to worry about her and wait. A former communications major in college, she has written eloquently about her experiences that began in December 2014: “I didn’t know that being drenched in sweat and layered with gritty dust would make me feel so engaged, so intent in the purpose of being, so deliberate in the work.”
The memories, though harsh, retain a certain beauty. Coyle remembers Ebola patients setting up a picnic. “A grandmother had gathered a group of patients around her to care for them,” she explains. A very ill granddaughter was tucked beside her; a grandson stood crying over his mother’s death. She encouraged an unrelated mother to bring her baby to the blanket as well. And amid the death, the fear, and the suffering, indeed there was a picnic.“The grandmother had created a moment of peace and normalcy,” says Coyle. “Not all gathered on that blanket that night survived Ebola. But I think of that memory fondly, for that grandmother was a portrait for the strength of women caregivers who, in the face of powerlessness and despair, display extraordinary courage and resolve to care for those around them.”Your Sense of Place
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