Keywords

Health care; Nursing; Medical mission; Electronic health record; Patient education

Introduction

When a group comes together with a mutual goal, great things can happen! In January 2017, I had the opportunity to travel to Haiti as part of the Sigma Theta Tau, Region 14, and medical mission team. Sigma Theta Tau, Region 14, partners with the Foundation for Peace, who provides in country support during the mission. Our projects are done through short-term mission teams supported by in-country staff, and focus on four main areas: body, mind, spirit, and community [1].” Our mission trip was in line with the “Standards of Excellence in Short Term Missions,” including God-centeredness, empowering partnerships, mutual design, comprehensive administration, appropriate training, and thorough follow-up [2]. The Foundation for Peace is involved in medical missions, clean water initiatives, building schools and churches, and providing community outreach programs in Haiti, Dominican Republic, and Kenya [1]. The beginning of the Foundation for Peace dates back to 1962. Sigma Theta Tau, Region 14 has been partnering with the organization since the mid-2000s.

Medical mission trips have their challenges, but can be life changing for both the providers and receivers of care. This article will focus on a medical mission trip to Haiti, the least developed country in the western hemisphere, and one of the poorest in the world [3]. Haiti was devastated in January 2010 by an earthquake that struck the nation, taking the lives of approximately 220,000 people, and crippling their infrastructure and economy. Over the years Haiti has suffered from the Cholera outbreak in October 2010, which has affected approximately 780,000 people and claimed the lives of about 9,100 [4]. Most recently, Hurricane Matthew ravaged the nation in October 2016 affecting over 2 million people by destroying homes, food sources, and water and sanitation services, to name a few.

Over the course of a week, a group comprised of mostly Registered Nurses, Nurse Practitioners, and nursing students provided health care to approximately 1,800 people from Canaan, Timache, and La Hatte Cotin, Haiti. In addition to our volunteers, we were assisted by two Haitian physicians and multiple translators. Although the goal of serving there was to provide great health care to the people of Haiti, the lives of the providers were also changed. We learned about the Haitian culture and the strong impact their spirituality has on their lives; the clinical education experience provided to the nursing students was exceptional; and practicing nurses were able to further develop their teaching and leadership skills.

Health Care

The main focus of our mission was to provide free primary health care to the families in need. Four clinics took place over the course of the mission, serving over 1,800 people. Three of the clinics were all day events, lasting about 8 to 9 h each day. The last clinic was at an orphanage and lasted about 4 h. Each team would see about 45 people each clinic day. The care needs varied by client ranging from well child visits to wound care to hypertension treatment. In some cases, such as hypertension treatment, further observation was needed after treatment and clients were monitored and reassessed by the registered nurse and nurse practitioner before they could be cleared to leave. The clinics were scheduled by the Foundation for Peace who works with the surrounding community leaders to prioritize need and establish the clinic site. The sites were set up in the community churches. We treated conditions such as scabies, tinea corporis (ringworm), hypertension, community acquired pneumonia, wounds, headaches, malnutrition, parasitic infections, and other bacterial and fungal infections.

With limited resources, we were not equipped to handle all situations. For example, one patient came to our clinic in labor because she heard there were doctors and nurses there that could help her. Upon assessment it was decided that the patient should go to the hospital, and we provided her with transportation there. Another patient presented with difficulty breathing and had a low pulse oximetry reading. After assessment the team decided to transfer her to the hospital. This patient was accompanied by one of the nurses and translators to monitor her in route.

Medications were provided based upon their diagnosis. We were able to provide medications such as pain relievers, fever reducers, antibiotics, antifungals, antacids, and vitamins. Medications and vitamins were collected by the volunteers and were brought with them to Haiti. As per the best practices for short term medical missions, expired medications, medications that were issued and then returned to a pharmacy or elsewhere, and medications that were given as free samples were not utilized [2]. Part of the preparation for the trip included a “packing party” where we were able to ensure there were no expired medications. We also took this opportunity to label each medication in Haitian Creole, and included instructions on use. The labels were created with the assistance of the Haitian translators to confirm clarity and understanding. Upon administration and when given a supply of medication, the teach-back method is utilized. The instructions are provided with the assistance of a translator. The patient must be able to explain back what they are prescribed each medication for and how to properly administer the medication. In addition, the patient is educated regarding any side effects of the medications and proper storage of the medication if warranted. Sometimes patients presented with conditions that needed further follow up, or needed non emergent services that we could not provide, such as dental and ophthalmic services. We were able to provide referrals for those patients to the community or church leaders who would assist the patient further in getting the services they needed.

In addition to medications, we provided the patients with hygiene kits that consisted of basic necessities such as soap, wash cloth, tooth brush, and toothpaste. Patient education is a key factor as we provided information on medication administration, diet, hydration, proper hygiene, health promotion, and disease prevention. One success story is that of a young boy who one of the nurse volunteers has now seen for the second time. She stated “I first met him two years ago as a fairly uncomplicated yet far too common diagnoses of skin issues, abdominal parasites, and decreased appetite. Because of the combined efforts for clean water projects, our medical clinics, and your generosity, he has since, so far, only needed a well-child exam from us” – Raissa Lynn Sanchez, BSN, RN.

Education and Leadership

Opportunities to learn were abundant for all. Each clinic day about ten teams were formed that consisted of a Registered Nurse to one or two nursing students and a translator. The nursing students were encouraged to prepare prior to the trip by refreshing their assessment skills and learning the common medications that are provided to the patients. Each team saw five patients at a time. The nursing student would need to help triage patients and be sure they received the proper care and medication based off the provider’s recommendation. In addition to physical assessment, students could perform skills such as vital signs, glucose monitoring, wound care, medication administration, and patient education under the direct supervision of the Registered Nurse and Nurse Practitioner. Proper documentation of assessment, treatment, and prescriptions given were performed in an electronic health record. Students performed within the same scope of practice as if they were in the United States. All care was performed under the direction and oversight of a licensed Registered Nurse.

As a Registered Nurse, valuable teaching and leadership skills were gained. The Registered Nurse was in charge of the team. They would make sure the students were assessing appropriately, guide them during their assessment questions, teach them how to give proper report, ensure proper referrals were given in order to provide services not available at the clinic, and create a solid team working dynamic to ensure great care. The Nurse Practitioners were available for additional support, assessment, and to prescribe the necessary medications.

Debriefing was a significant aspect of the experience that occurred after each clinical day. Debriefing is an information-sharing and event-processing session conducted as a conversation between peers [5]. These sessions are important to bring members together to acknowledge shared distress, to affirm the groups suffering, and to assist the group in coping [5]. The group of 35 members was separated into four small groups to discuss the day’s events. Experienced members of the team who have participated on the mission trip in the past led the groups. The debriefing period was referred to as “The Happy-Crappy.” Each team member had the opportunity to express what the best aspect of their day was and the most difficult. Examples of the “happy” included the amount of people we were able to help and provide care to, the learning that occurred, and the exceptional dynamics of the team. Examples of the “crappy” included that we still wanted to help more people, the lack of clean water and sanitation services, limited resources, and when we had to send individuals to the emergency room who were too sick for the service we could provide. After the last day we met as one large group and discussed what worked best and areas of improvement for future years as well. As the group came together and reflected on the experience, emotions ran high. There were periods of happiness, sadness, and anger. The debriefing period assisted the group members in rebalancing after the experience of the day’s and week’s events.

Spirituality

Spirituality was observed to be a major part of the Haitian culture. About 80 percent are reported to be Roman Catholic, 16 percent Protestant, and approximately 50 percent practice voodoo [6]. During my time there I did not witness any voodoo practices. The organization partners with in country churches and community leaders to prioritize community needs and develop plans to meet those needs. Each clinic site was held at the church of the communities we served. The pastor would say a prayer at the beginning and end of each clinic day. The people were so passionate and their faith seemed to help move them forward even though they have suffered so greatly. The members of the healthcare team also had the opportunity to worship with the members of the community. The service was performed in both Creole and English. There were prayers for Haiti, prayers for the community, prayers for family and friends, and prayers for each other. With this working hand in hand with the community, year after year, lasting relationships are formed (Figure 1).

Figure 1: Healthcare team.

Reflection

Serving the people of Haiti was an invaluable experience, and I plan to continue to serve in the future. A thought running through my mind and others is what the sustainability is? We see the patients and give them limited supplies of medications. What happens next? A major role we play as nurses during these mission trips is patient education. Even though the medication supply is limited, the education provided is forever. For those that need daily medication, such as anti-hypertensives, the goal is that the church or community leaders can assist them in receiving follow up care for the conditions. Those patients identified were provided with written referrals for follow up care to be arranged with the community leaders [7-10].

The organization I served with is dedicated to working with the underserved communities to build sustainable projects and relationships. Besides medical care, they work on clean water projects, schools, and church building projects. These are all important aspects needed to build healthy communities. They do not “own” projects, but rather make long term commitments to their partner communities and churches so they will be able to sustain the projects on their own [1].

Being aware of the potential to cause harm while wanting to help is imperative. Short term medical mission teams have potential to cause harm. For example, unfamiliarity with the patient population, the language, and common health problems as well as the short term nature of the trip can lead to inappropriate and unsustainable treatments [11]. In addition, there are concerns of utilizing expired or sample medications, practicing out of scope, and being unfamiliar with the practice standards of the host country [11]. My experience with Sigma Theta Tau and The Foundation for Peace was very positive. We were adequately prepped prior to entering the host country through electronic materials, web assisted meetings and in person meetings. No expired or sample medications were utilized, and they were labeled in the native language with the assistance of native speakers. All care was provided within the scope of practice of the clinician. Each team was paired with a translator for proper communication. Full patient understanding of medications was ensured through the teach-back method. Acknowledging and being aware of the potential to do harm is the first step in minimizing negative outcomes that may occur as a result of common practices of short-term mission teams [11]. It is important to research the organization in which you will be serving with to ensure they are an established, respected group [11].

Discussion and Conclusion

Many of the volunteers reported wanting to “do more” and “I wish we could help more people.” Although it is great to think that way, we need to realize we cared for over 1,800 people in 24 clinic hours (Figure 2). That is a great accomplishment and we made an impact on those individual’s lives. Hopefully, those we served and educated can share the knowledge with the other community members and impact their lives as well. Sigma Theta Tau, Region 14 and The Foundation for Peace have been committed to and partnering with the local community for years. In the future, being able to establish long term goals of training health care workers, establishing long term funding, and building relationships with the local health authorities may assist in a more sustainable system. Further research and insight is needed in the area of sustainability for short term medical missions.

Figure 2: Educating the knowledge with community members.

References

1. https://www.foundationforpeace.org/our-work/
2. https://www.csthmbestpractices.org/ConsensusDocuments.html
3. https://worldbank.org/en/country/haiti/overview
4. https://www.un.org/News/dh/infocus/haiti/CholeraFactsheetAug2016.pdf
5. Hanna D, Romana M (2007) Debriefing after a crisis: What’s the best way to resolve moral distress? Don’t suffer in scilence. Nurs Manag pp: 39-47.
6. https://magazine.nursing.jhu.edu/2010/04/spirituality-of-the-haitian-people/
7. Rovers J, Andreski M, Gitua J, Bagayoko A, DeVore J (2014) Expanding the scope of medical mission volunteer groups to include a research component. Glob Health 10: 7.
8. Yao CA, Swanson J, McCullough M, Taro TB, Gutierrez R, et al. (2016) The medical mission and modern core competency training: a 10-year follow-up of resident experiences in global plastic surgery. Plast Reconstr Surg 138: 531e-538e.
9. Sykes KJ (2014) Short-term medical service trips: a systematic review of the evidence. Am J Public Health 104: e38-e48.
10. Mckay A (2007) Towards a history of medical missions. Med Hist 51: 547-551.
11. Hawkins J (2013) Potential pitfalls of short-term medical missions. J Christian Nurs 30: E1-E6.