Nursing without borders
Carol Ziegler’s great-grandfather was a Rough Rider, charging into battle with Theodore Roosevelt during the Spanish-American War. He had an intimate view of the effects of foreign intervention and hammered into his descendants that cultures were to be respected, not interfered with.
The night she graduated from Vanderbilt University School of Nursing’s Family Nurse Practitioner program, Ziegler met her future husband, a Kenyan named Kipkosgei Magut. Just a few months later, she was traveling to Kenya to meet his family with her great-grandfather’s longstanding admonishments ringing in her ears.
“As soon as his family heard I was a nurse they said I should start a clinic there. But I looked around and saw people in their 90s and one over 100 with all their teeth. I thought, ‘You don’t need me!’”
But she was interested in the state of health care in this very remote village, especially when she learned that Magut’s mother was an herbalist.
“They’re using artemis for malaria, which effectively treats malaria the same as the drugs we use. They deal with skin disease, a lot of cancer, some high blood pressure and diabetes. The main thing they’re lacking is trauma care,” Ziegler said.
They were also facing a health care worker shortage because all of the herbalists were older than 65 and few younger people were learning their trade. While Ziegler completed her Doctorate of Nursing Practice at VUSN, she decided to use her culminating scholarly project to interview the village’s traditional healers about their world view and practice and archive the information for the future.
“We found many barriers to their practice. The government has started protecting the forest, which is great for the plant and wildlife, but doesn’t allow these healers to go in and get the herbs they need. The government is also requiring licenses, which can put some competent healers out of practice. Now biotech companies are pirating the herbs that these villagers have developed over thousands of years. When all these tribes are involved, who gets the patent?” said Ziegler, who is now assistant professor in the FNP program and coordinates VUSN’s global health programs.
Ultimately, Ziegler learned the lesson that VUSN emphasizes in all global health work, and one her great-grandfather would approve of—whatever you do, it must benefit the community.
“It’s really important from Vanderbilt’s perspective that whatever we do outside our borders we do because the people want us to be there. We could come up with all kinds of things that would be great learning experiences for students, but it also has to be good for that community,” Ziegler said.
With technology and travel making the world increasingly more accessible, more and more students are entering VUSN with a desire to participate in global health. Many have been on mission trips, served in the Peace Corps or studied abroad during college.
“I repeatedly hear from those students that when they were abroad they realized how important health was and that inspired them to be a nurse. They want to have the knowledge and skills to go back and make a difference,” said Mavis Schorn, PhD, CNM, senior associate dean for Academics. “That’s the nature of this next generation. They’re much more traveled and very concerned about the wider world and its needs.”
The school recently added a special session during the campus visit to talk about international programs because they were fielding so many inquiries.
“Our challenge is trying to fill their desire for global health and still meet, in a very compact time, their requirements in order to practice in the U.S.,” Schorn said.
VUSN students, faculty and alumni participate in patient care, education and research around the globe, with the belief that experience and understanding about people from diverse populations enhances the quality of health care that can be provided in any location.
One of VUSN’s biggest partners is the Vanderbilt Institute for Global Health, which provides multidisciplinary research and training programs worldwide. Its elective courses are open to students across the University.
“Foundations of Global Health” takes a theoretical look at the state of global health and what can impact it beyond the disease burden, including the environment, socio-economic and political climate, culture and history of a place. “Foundational Skills in Global Health” is more practical with lessons on core field tools, needs assessment, implementation techniques and methodologies.
“Leadership Development in Global Health” is a new requirement that emphasizes leadership and management skills.
“There are a lot of people who want to do missions, but actually making that a reality in a substantive way can be very challenging. We are encouraging students to do more than a parachute in or out experience, and that a very real need in many global settings is to have good clinicians who are also skilled in leadership and management,” said Carol Etherington, MSN, RN, FAAN, associate director of Community Health Initiatives at VIGH and associate professor of Nursing at VUSN.
Etherington began discussing global health with former VUSN Dean Colleen Conway-Welch in 1998, “long before global or international health was sexy or even seemed in the realm of possibility,” she recalled.
“We began a series of meetings called the VU-triple I, which stood for International Interdisciplinary Initiatives, with the law school, divinity school, medical school, nursing school and business school. It has always been special to me that the conversation was started in the School of Nursing,” Etherington said.
Today, VUSN is again a pioneer, this time in ways to incorporate global health into a demanding curriculum.
Mary Martin, CNM, was the first nursing student to complete VIGH’s Graduate Certificate in Global Health. While the certificate usually requires an overseas practicum, Martin focused on Arabic-speaking immigrants in the Department of Obstetrics and Gynecology at Vanderbilt, facilitating patient education through group settings to teach women to participate in their own health care.
“It was not at all a contrived placement. It was global health, without question, in a most innovative way. We really do think that global health can be done at home, and it’s the nursing students who are frontrunners with that concept,” Etherington said.
Project Pyramid, operated out of Owen Graduate School of Management, is another strong global health partner for VUSN. Approximately 35 students from across Vanderbilt’s graduate schools do coursework and plan and execute a spring break service trip. Past trips have included Guatemala and Nepal.
In addition to global health, students are immersed in interprofessional learning.
“Other students really appreciate having the nurses’ well-developed and sophisticated view of health care on the ground as it is really delivered, and the nurses really learn from business, engineering and law students. They all work beautifully together,” said Bart Victor, Cal Turner Professor of Moral Leadership and Project Pyramid faculty leader.
Schorn said Project Pyramid emphasizes that global health can’t succeed without teamwork.
“You can treat for worms all day long, but if you haven’t worked with the engineer to improve the water supply, you’re not going to get very far. The more they learn how what one does impacts the other and learn to work together, it ultimately improves the whole,” Schorn said.
It has been Etherington’s long-held vision that nurses be an integral part of any global health team.
“With those very chronic and complex problems, where health is directly related to the environment, education, economics and the geopolitical issues going on, I think that nursing is the profession that has its finger on the pulse of how all those issues come together. But rarely are nurses pulled into the decision making in a lot of places,” she said.
That vision is partially realized this fall with the first participants in the Global Health Nurse in Residence Program, an opportunity for Vanderbilt affiliated nurses to serve, train, network and collaborate with nurses and other health care workers for up to 12 weeks in the Central Province of Kenya.
Supported by VUSN alumna Poppy Buchanan, this program is the first to focus solely on providing nurses and nurse practitioners with a funded opportunity for a global health immersion experience. Grace Appert and Laine Scott-Nelson were selected as the inaugural Nurses in Residence.
“We always emphasize how important it is to be sensitive to the uniqueness of each culture and ethnicity,” Etherington said. “But the reason nurses are so important to this effort is that with all of those differences, at the heart of global health is the understanding that there really isn’t that much difference in human beings. And nurses get that.”
Zambia and Nicaragua
Michelle Drew has made it her mission to “infect” the next generation of nurses with the global health bug.
“Teaching students, I try to reinforce the idea to work in a resource-poor area.
I want to equip them with the knowledge, understanding and desire to work in those areas. It’s amazing to me that the idea of ‘service’ has become so ingrained in the U.S. and I hope it continues. It’s important to expose students to the idea of caring for ‘the least of these.’”
Drew has spent more than a decade doing just that in rural Zambia and Nicaragua. It started with a medical outreach trip to Zambia in 2001 and quickly turned into a full-time position in a mission-based hospital there.
“I first studied tropical medicine and then came to Vanderbilt to earn my MSN in Nurse-Midwifery/FNP program to give me the training I needed to be able to serve the whole community, but women and children were my passion from the start because I was struck by the disparity and how the position of women and children in the prevailing culture affected the health care they received.”
Even though the World Health Organization recommended pregnant women be treated with anti-malarial drugs in their third trimester, the patriarchal society gave first priority to males and first-born children.
“You have to really take the cultural temperature and develop relationships to institute change. It’s easy to walk around as a bull-in-a-china-shop American, but that wouldn’t have gotten me anywhere. I can’t overstress cultural competence,” Drew said.
After 10 years in Zambia, a desire to be closer to her aging parents led Drew to a non-governmental organization in Nicaragua that develops community-based maternal/child health networks and trains and supports traditional birth attendants and midwives.
“The geography is very mountainous and volcanic. Getting women to come down to the hospital for an attended birth is not always feasible. They still tend to deliver at home, and our goal is to have trained women there with them,” Drew explained.
The non-governmental organization provides a casa maternal to feed and house the women who travel down from the mountains before delivery.
Drew also leads students on international trips and has seen the global health “buzz word” grow over the years.
“I went from maybe once a year getting a student inquiry to now turning people away in droves,” she said. “To go from seeing problems all due to our sedentary lifestyle—knee pain, diabetes, high blood pressure—in the U.S. to being in Nicaragua seeing scabies and pin worms is an eye-opener. I hope it reinforces their desire to work with the underserved, even in the U.S.”
When Stephenie Plowden’s husband received a Fulbright Fellowship to study in South Africa, she immediately looked into ways she could join him and continue her Nurse-Midwifery/FNP studies there. The answer was a five-month independent study through the University of Cape Town, which has a partnership with Vanderbilt University.
Plowden worked in a state-sponsored birth center that is the primary level of care for pregnant women without private insurance.
“Women don’t have an option. There are no epidurals, no continuous fetal monitoring, no Doppler. You could definitely say it was low resource.”
The center averaged 400 births a month in six delivery beds. Delivering at least two herself every shift, Plowden quickly went back to basics.
“I learned to palpate where the baby was lying to get the best heart rate. We don’t do that in the U.S. because we have machines. In South Africa, my main tools were my hands, ears and eyes.”
But, she emphasized, her greatest tool was humility.
“Being an intruder or guest, I learned to put aside what I saw in my world view as best practice and took in what they could share with me. It takes humility to learn from each other and to value our various backgrounds and experiences. I didn’t want to make the mistake of playing God and telling them how they should reform their country and save Africa. I saw a lot of goodness in many things they do that we lack.”
Plowden noted a great disparity between the educated health provider and the uneducated patient and was often frustrated with providers who didn’t listen to their patients or give them time to express concerns.
“Through these experiences, I know I’m a better midwife, but I feel like I’m a richer person by the impact of these South African women. I’m inspired by what they endured, and I never want to be too busy to explain something or to reassure someone who is scared.”
After graduation in May, Plowden would like to focus on providing the midwifery model of care to marginalized women in the U.S.
“I feel like immigrants and refugees and other marginalized women often receive substandard care because they don’t know how to get anything better. I want to empower women through birth, and that starts with women who are not empowered in life.”
Erin Dittmer, an adult and women’s health nurse practitioner student, just spent seven months in Beijing studying Chinese as a David L. Boren Fellow.
Sponsored by the National Security Education Program, the David L. Boren Scholarships and Fellowships are a federal initiative designed to build a broader and more qualified pool of U.S. citizens with foreign language and international skills. In exchange for funding, Boren award recipients agree to work in the federal government for at least one year.
Dittmer taught English in China for 13 prior to entering VUSN, and seeing the SARS outbreak there contributed to her decision to change fields. During her fellowship, she was a full-time language student and arranged some clinical observations and language exchange with local health care students to acquire more medical vocabulary.
For anyone interested in working long term with a non-English speaking population, Dittmer encourages investing time in learning the population’s language.
“Besides the practical skill of being able to use the language for communication, the experience of being a foreign language learner helps to develop empathy for those we encounter in the U.S. whose first language is not English,” she said.
“As health care providers, we need to remember how vulnerable patients feel when they are in need of medical care but don’t understand what is going on around them or can’t express themselves clearly because of language differences. Both living abroad and studying a foreign language can help to cultivate this awareness.”
Faculty goes global
Global health activity at VUSN is not limited to students. Many faculty members have formed collaborations at Queen’s University in Belfast, Ireland, Hong Kong University, and Melbourne University in Australia.
In September, Karen D’Apolito, PhD, APN, NNP-BC, FAAN, professor of Nursing and director of the Neonatal Nurse Practitioner Program, will spend five days at Queen’s University to explore possibilities for cooperative research or faculty exchanges.
“I plan to meet the faculty, visit their nurseries and talk about ideas for collaboration. I’m seeking information. Once I find out more about what they do and what they’re interested in, then we can decide the best way to move forward,” D’Apolito said.
She said she is excited to see how differently the Irish manage newborns and how they teach students, and says learning from other nations can inspire new innovations.
“They may educate students differently than we do here in the U.S. Do they use distance education and/or problem-centered learning? What is required for faculty education? These exchanges of information may lead to new and different teaching strategies that can enhance the education of students in the U.S. and abroad.”
– by Leslie Hill