536585
research-article2014
TCNXXX10.1177/1043659614536585Journal of Transcultural NursingLal and Spence
Article
Humanitarian Nursing in Developing Countries: A Phenomenological Analysis
Journal of Transcultural Nursing 1–7 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614536585 tcn.sagepub.com
Shane Lal, RGON, BN, MHSc1 and Deb Spence, RN, RM, PhD1
Abstract Background: Surgical nursing within humanitarian contexts is complex, sporadically described in literature and little understood. Aim: To achieve a deeper understanding of the lived experience of New Zealand nurses providing humanitarian aid within surgical settings and war zones in developing countries. Method: In-depth conversational interviews were undertaken with four New Zealand nurses whose humanitarian experience lay in general surgical, military, and intensive care settings. A qualitative descriptive method as described by Sandelowski, informed by van Manen’s phenomenology in terms of analysis, was used. Results: Specialized knowledge and nursing expertise are recognized to be essential but not sufficient for humanitarian work. Understanding local cultures contributes to positive feelings about work effectiveness. Themes included feeling anxious and misunderstood, practicing differently, and adjusting to life back home. Discussion: This study highlights the need to better prepare nurses who volunteer for humanitarian work, with implications for recruiting organizations, educators, and clinicians. Keywords international educational experiences, qualitative research, cardiovascular, medical/surgical, military
Introduction Travel to exotic and war destinations for humanitarian work seems exciting and heroic to many health care professionals, including nurses. These ventures provide personal and professional growth. They also offer insight into the cultural, political, and socioeconomic climate of nations whose health care provision differs vastly from that of the developed world. However, nurses’ work in developing zones is accompanied by concerns for the rationale behind the delivery of appropriate care to the recipients. The fact that cultural and ethical issues encountered in humanitarian work often clash with the personal and professional values of workers from foreign nations has been highlighted by Hunt (2008). Additionally, questions pertaining to humanitarian work effectiveness and sustainability have been raised by Hunt (2011) and Markus and Zwi (2002). There is an increasing demand for effective global health service development (Bunyavanich & Walkup, 2001; McQueen et al., 2010). Despite inadequate information available on the needs of surgical services in developing countries, humanitarian interventions continue to be provided to improvised communities (McQueen et al., 2010). Good intentions and professional and moral obligation to assist people in need are cited as the main reasons for participating in the provision of such care (Pezzella, 2006; Sommers-Flanagan, 2007; Tschudin & Schmitz, 2003). A wide range of attributes have been identified mostly in relation to those working in military operations or postwar situations, primary health care, and emergency
situations (Agazio, 2010; Bjerneld, Lindmark, McSpadden, & Garrett, 2006). Relatively little research has been published of nurses’ work in surgical contexts. Therefore, the aim of this study was to achieve a deeper understanding of the lived experience of New Zealand nurses providing humanitarian aid within surgical settings in developing countries. For the purpose of this study, the term humanitarian work or humanitarian aid, used interchangeably in this study, is defined as volunteering personal and professional skills as well as time to assist populations in war zones and resource-poor countries.
Review of Literature Factors recognized to generate the need for humanitarian aid include the effects of economic, social, and environmental impact on developing nations (Pezzella, 2006). The World Health Organization, the United Nations, the World Bank, government organizations, nongovernment organizations, and charitable bodies such as the International Committee of the Red Cross and faith-based organizations are agencies whose contributions and health initiatives have made a positive difference to millions of people (Belcher & DeForge, 1
Auckland University of Technology, Auckland, New Zealand
Corresponding Author: Shane Lal, 8 Warwick Street, Western Springs, Auckland 1010, New Zealand. Email: [email protected]
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2007; Bunyavanich & Walkup, 2001; Dufour, De Geoffroy, Maury, & Grunewald, 2004; Frossard & Bojarska, 2007; Jayasinghe, 2009; Pezzella, 2006; Ruger, 2005). Recent research relating to humanitarian work has focused on work effectiveness, sustainability of services, and imposition of Western values on developing nations (Thieren, 2007). There are now principles and codes of conduct for humanitarian workers involved in the developing world (International Federation of Red Cross and Red Crescent Societies, 1995; Sommers-Flanagan, 2007; Thieren, 2007). However, the transferability of codes and principles relevant in Western health care to developing countries remains problematic (Bell & Carens, 2004; Hunt, 2008; Markus & Zwi, 2002). Ideally, the delivery of all humanitarian work should be bound by standards and protocols that respect the infrastructure and culture of the recipient nation (Dufour et al., 2004; Pezzella, 2006). However, Marcus and Zwi (2002) have clearly demonstrated the dominance of foreign teams on institutional arrangements and structures of local services. This study demonstrated the significance of the need for partnership in humanitarian work. Nurses contribute to government organizations, such as the military and naval forces. These organizations facilitate short- and long-term humanitarian missions (New Zealand Red Cross, 2009) and adhere strongly to the World Health Organization-UNICEF Alma-Ata principles to attain health outcomes acceptable by the impoverished communities (Frossard & Bojarska, 2007; Thieren, 2007). The complex nature of delivering humanitarian aid has been articulated by numerous authors (MacRae, 2008; Markus & Zwi, 2002; Parfitt, 1999; Pezzella, 2006; Pupavac, 2004; Walsh, 2004; Zinsli & Smythe, 2009). Working with awareness of local resources and in collaboration with local teams has been identified as empowering and promoting independence in local communities (Heck, Bazemore, & Diller, 2007; Parfitt, 1999; Walsh, 2004). Parfitt (1999) found that “power” is utilized by nurses in practice both to empower and/or to increase dependence on the services provided by the donor nations, thus overriding the humanistic values of beneficence, which often initially attract nurse to humanitarian work. Bell and Carens (2004) similarly reported that Western humanitarian workers and organizations may not be familiar with unexpected complications in developing countries or know how to deal with the subtle behavioral nuances of people with different cultural and political systems. Researchers who have explored cross-cultural nursing experiences more generally assert that recognizing the power differentials inherent in health service delivery is essential for effective clinical practice (Spence, 2001). Furthermore, the well-known cultural theorist Madeleine Leininger in her seminal ethnographic work of the Gadsup culture in the highlands of Papua New Guinea argued that “very serious ethical and moral issues can rise if health care professionals
make assumptions and decisions based on western child and adult rearing practices that do not fit non-Western or under developed people” (Leininger, 2002, p. 217). Phenomenological research undertaken by Hunt (2008) sought to gain deeper understanding of the ethical issues and moral reasoning employed by Canadian health care professionals working in developing countries. Participants were reported to struggle to respect local customs and beliefs that clashed with their own values. Differing understandings of health, illness and death created dilemmas and barriers to providing care appropriate to the locals (Hunt, 2008). A more recent qualitative study of doctors, nurses, midwives, and human resource and field workers by Hunt (2010) reports that humanitarian work is a morally complex activity that requires preparedness, support, and strong motivation. This is further complicated when the increasing cultural diversity of humanitarian workers adds to the varied and complex nature of ethical issues and their subsequent resolution (Hunt, 2008). An exploration of perception of humanitarian work highlighted preparedness, professional competence, and previous experience of humanitarian work as key factors to achieving better outcomes (Bjerneld, Lindmark, Diskett, & Garrett, 2004). A later study by Bjerneld et al. (2006) reported a strong desire to contribute for reasons of personal development and satisfaction. Both studies also highlighted health care professionals’ concerns of personal security and professional competence for undertaking such work. However, the motivational needs of health care professionals to engage in humanitarian work in these study findings present a strongly Western perspective. New Zealand, despite its small size, has always played a significant role in humanitarian missions (Caughley, 2001). An exploration of New Zealand nurses’ experience of humanitarian work reported by Zinsli and Smythe (2009) revealed concerns about personal security and differences in culture and practices of people. Paradoxically, the findings also suggested that it was the New Zealand nurses’ ability to cope with a variety of challenging situations that drew them to volunteer again. Army nurses’ experiences are similar to those experienced by many nonmilitary humanitarian missions (Agazio, 2010; Bjerneld et al., 2006; Crawford & Harper, 2001; Hunt, 2008, 2010; Zinsli & Smythe, 2009). Agazio (2010) reports that army nurses practicing in military humanitarian missions require specialized skills and personal adaptation under austere conditions. Preparation in relation to ethical, moral, and cultural conflict experiences has been recognized by Bjerneld et al. (2004), Hunt (2008, 2010), and Parfitt (1999). Although the focus of this literature search was nurses’ experience, the studies reviewed had both a nursing and a combined health care professional focus. The literature reveals an emphasis on concepts such as power, ethics, values, and motivation and health care professionals’ perception of humanitarian aid work. It provides insight into the overlapping issues of ethical and moral dilemmas, cultural difference, and
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Lal and Spence power differentials in the context of primary care, hospitals, emergency settings, and postwar conflict zones.
Research Approach A qualitative descriptive approach as described by Sandelowski (2000) with thematic analysis informed by van Manen (1997) was used to achieve a deeper understanding of this complex phenomenon. The study was approved by and met requirements of the Auckland University of Technology Ethics Committee. Purposive sampling was used to recruit nurses who had experienced humanitarian nursing within different surgical contexts in developing countries. The four participants comprised two male and two female nurses. Their ages ranged from late 20s to mid-forties. The participants’ reported a total contribution of 18 years’ humanitarian work. Areas of work experience included pediatric cardiac intensive care, general intensive care nursing, and military nursing. They had undertaken between one and nine missions. The duration of missions lasted from 2 weeks up to 9 months. Participants’ real names were replaced with pseudonyms, to maintain anonymity in the reporting of data excerpts. Data were collected via digital voice recorder, in one faceto-face interview session with individual participants. The interview questions focused on their experience of humanitarian missions and commenced with unstructured, openended questions: “How did you become involved in humanitarian work”? “Can you describe a recent humanitarian work experience as in much detail as possible?” “What were your hopes and fears”? Follow-up questions were based on data that the participants were providing and its relevance to the research question. The use of a nod, an “mm,” or a pause allowed time for thinking and encouraged the participants to provide rich descriptions of their experience (Kvale & Brinkmann, 2009). Interviews lasted 40 to 90 minutes and the audio-recorded interviews were immediately transcribed by one transcriber, who completed a confidentiality declaration.
Interpretive Analysis The “consistent selective reading approach” outlined by van Manen (1997, p. 93) required looking for sentences, statements, and phrases that seemed particularly revealing of the experience of working in developing countries. The process involved isolating structures of meaning and removing extraneous aspects of the stories (van Manen, 1997). The dialectical nature of interpretive process required the researcher to move between the parts and the whole text to construct successive or multiple layers of meanings while maintaining a strong focus and orientation to the research question. During analysis, personal experience as a humanitarian nurse worker enabled insight into participants’ humanitarian experience. The author’s own experiences of humanitarian work had been articulated prior to commencing data collection and
therefore the author needed to be aware of ways these were influencing the analysis. Thus, supervisor guidance was regularly sought during the processes of thinking, selecting the most appropriate excerpts, writing and rewriting interpretations, and formulating tentative themes. These processes eventually culminated in a thematic description of the phenomenon as a whole.
Findings Close examination of nurse’s accounts revealed the following sequential themes: 1. Feeling anxious, worrying, and being misunderstood 2. Practicing differently 3. Adjusting to life back home Pervasive throughout was the overarching theme of Adjusting and Readjusting. The first theme describes nurses’ perceptions of humanitarian work, arrival into the recipient country, and adaptation with the donor and recipient teams. It reveals the precarious position in which the nurses find themselves as they adjust to the complexities and issues encountered within the initial phase of humanitarian aid work. The second theme captured the positive responses to challenges of practicing in less affluent nations where there are diverse ethical, moral, and professional challenges. The final theme highlights a realization of the disparities in health care and human suffering and the time needed to readjust to work and life in one’s home country alongside continued commitment to humanitarian nursing.
Feeling Anxious, Worrying, and Being Misunderstood Nurses experience feelings of anxiety, trying to fit into the team, being misunderstood, working to gain trust, and worrying about safety, although time constraints hasten the ability to find a place in the team. This is more evident in nurses on a first mission than those who had previous experience of humanitarian work. The teams consist of people from different countries, each person with his or her with own specific culture, language, and practice expertise. Finding one’s place quickly within the team provided incentive and drive for work performance. One participant described her first meeting with the team as their work began: You basically bounce ideas around to get a feel for how nurses work. The team works surprisingly well with each other and I think that’s partly because everybody is in the same situation. Everybody is new, nobody knows anyone. You basically have to place your trust [in them] quite quickly. (Kate)
Understanding teamwork requirements and others’ expertise is vital for effective collaboration as work commences.
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Common to all is feeling that there is work to be accomplished. Those who had previously worked in humanitarian missions knew that having a common purpose was critical but also knew personalities could disrupt teamwork. I think as long as everyone keeps it in mind what they’re there for, it worked well. When people’s individual egos get in the way, then it breaks down and things don’t work so well. (Nancy)
In addition to being anxious and worried about his or her specific place in the visiting team, the nurses also take on leadership roles, guiding and mentoring local colleagues. Adjusting to these supportive leadership roles is also anxiety producing. Faced with barriers of language, cultural difference, and lack of resources, the nurses feel a strong sense of respect for the host nation’s space and values, believing it morally wrong to provide advice without knowing what was important to the local team. One has to know and respect the other culture before stepping in, and not knowing how much English they would be speaking made it harder. This was part of the problem. It was either lack of equipment, or lack knowledge. . . . I tried to stay back and act as a mentor rather than taking over. The local nurses became colleagues very quickly but in the end, they turn to you for support, which is quite intimidating. (Kate)
In addition to the ongoing practice challenges, nurses on lengthy humanitarian missions lasting up to 9 months also faced personal adjustments relating to their living conditions. Prolonged time spent in close proximity with team members affects them both personally and professionally. We lived so closely, almost out of each other’s pockets for 9 months. Sometimes there was friction, but you just couldn’t just go home to a whisky. It’s a long [time] away from home. It became harder to maintain that enthusiasm as the time went on . . . But we still had to go on for we knew that it was a finite sort of situation . . . (Paul)
Other challenges inherent in humanitarian nursing are revealed through experiencing distrust and suspicion, especially from authorities in countries where tension and hostilities exist. This challenges professional values, codes of conduct, and the core value of caring inherent in nursing practice. When I arrived I got separated out, interrogated and searched. I felt nothing but hostility from immigration. I didn’t understand—how anyone could think that people are inferior because of their race or religion, sexuality, or whatever. I struggled with that. (Nancy)
Another participant was outraged by the tensions and misunderstandings associated with his humanitarian efforts: There was rumour circulating that the ship [Mercy Ship] was only there to steal organs from people—we were being accused
of organ theft! . . . their organs taken and sold overseas, this were utter rubbish! You try to do a good thing and there are always people who hate good things being done. (Mike)
Although this lack of trust was disturbing, the nurses worked to gain trust at the ground level with local health care professionals and patients. Those with previous humanitarian experience knew that building relationships, trust, and acceptance with the locals was achieved through showing a genuine commitment through successive returns to the same place. Humanitarian nursing in areas by war requires understanding and being patient with the local people, who are affected physiologically and psychologically. It took a little while to gain their trust but when they figured out that we were there to help, they were queuing up outside the compound . . . (Paul)
The nurses understand the importance of being sensitive to the needs of the people in any context. Patience, reassurance, and time were essential factors in gaining trust of the local people. Concerns about safety and security were commonly experienced, and staying close to team members was a way of coping with potentially life-threatening situations. Knowledge of continuing political unrest and the witnessing of some horrific scenes required them to be “extra vigilant and on guard at all times.” There was the threat that we could be killed by militia. It is an eerie feeling, it gives you goose bumps. You had to have someone with you at all times and carry your weapon, even as a nurse. . . . You had to be extra vigilant . . . (Paul)
Practicing Differently Practice differentials experienced by nurses related predominantly to resource constraint, lack of local expertise, and different clinical practices. Sensitivity to local limitations and a willingness to adapt and work within the local ways were evident in the nurses’ accounts. On the first trip, we tried until we were blue in the face to emphasize how important it was to do mouth care . . . it wasn’t going to happen no matter how many times we said—it just wasn’t a priority. Getting the child through the surgery and getting them home safely is much more important [to them]. (Nancy)
Although practicing challenged personal and professional values, the nurses adjusted their practice to respect local ways of thinking and different worldviews. In their environment families don’t get to visit. We couldn’t change their policies and say, “You must do family-centered care.” That takes a bit of getting your head around—yes, it’s
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Lal and Spence different to us but it doesn’t make them wrong and it doesn’t make us right. (Nancy)
Human and technical resource constraints were often problematic. The complexity of surgical intervention and intensive postoperative care required reliable equipment and clinical decision making that was different from their practice at home. The blood gas machine had broken; we couldn’t get magnesium at all. The ventilation wasn’t great. This child was off-color, the blood pressure was dropping and there was no one to turn to. . . .It often didn’t go as anticipated. There were a lot of complications with the kids. (Kate)
Linguistic barriers, levels of collegial support, and a more demanding nurse-to-patient ratio compounded these challenges as Mike explains, You’d be looking after 3-4 or 5 patients [in intensive care] so you find yourself running from one thing to next and getting used to. . . . different languages . . . it was not the same as I was used to New Zealand . . . (Mike)
There were also challenges to collaborative decision making and working within a scope beyond those legally required in their home countries (Nursing Council of New Zealand, 2007). The experience of providing humanitarian work to people in developing countries helps advance nurses personally and professionally. It develops an understanding of political and economic differences and numerous opportunities for problem solving. [The] huge range of experiences makes you a bit more tolerant of other people and other cultures. It makes me appreciate [resources]. I’m more tolerant person and more aware that there’s more than one way of solving an issue or a problem. When you’ve got limited resources, you learn to be ingenious, a bit more lateral thinking. . . . it has been really valuable to me personally and professionally. (Paul)
However, along with the many unanticipated and morally challenging situations encountered in humanitarian work, the experience overall is rewarding in a profoundly different way from nursing in their own country. Women with obstetric fistulas are ostracized by their communities and families, it’s pretty cruel. After their surgery, they’d have dress ceremonies, a passing-out parade for patients and they leave the ship with big smiles on their faces, they are given a new lease on life. Providing this sort of health care is enriching and satisfying. (Mike)
Nurses providing humanitarian service have often experienced the unselfish and overwhelming generosity of those who have very little: They are so welcoming and friendly . . . so open despite being beaten back time and time again. They will welcome you with
open arms every single time that you visit. . . . They had no money but when you arrived at their house, they would run down the road and come back with a bottle of carbonated soft drink that might have cost them 6-months wages just to be hospitable to you and to show friendship. It was just amazing . . . just amazing (Nancy)
Adjusting to Life Back Home Readjusting, following return from foreign humanitarian work, takes time. The nurses’ frustrations continue as they experience the lack of appreciation by nursing colleagues of resources and their taken-for-granted attitudes to New Zealand services. The wide economic disparities that affect the health care and people in developing countries are a constant reminder to the nurses in their initial phase of readjustment. The longer you’re away; the more you get soaked in the local experience and the local environment and the issues of that environment. … . . You can forget what it’s like to be much better off; just as I got absorbed in the way it was over there. . . [Here] you can use another piece of gauze or another pair of gloves or throw something away because it fell on the floor. You know there are plenty more in the cupboard. (Mike)
Returning to their technically advanced environments is hard because the memories of having to initially adjust to vastly different priorities and less than ideal ongoing treatment because of insufficient time and resources remain vivid. You can’t do complex surgery that will take three [stage] repairs over time because the patient’s family can’t afford medication. They might never get back there [home] again. . . . It’s really hard when you come from a society where you can throw money around into everything. (Nancy)
Adjusting and Readjusting In an overall sense, the experience of providing humanitarian aid in developing countries is one of recognizing the need to change one’s practice to align with the priorities, values, and resources within the local community. This often means accepting a focus on survival, for example, rather than providing for hygiene needs such as mouth care. It also means feeling anxious and scared about extending one’s practice beyond the level previously practiced at home. Significantly, it is an experience of feeling rewarded in ways not previously imagined. The nurse’s practice is less constrained than in his/her own country, and this release of potential is what draws them to return. The experience of humanitarian nursing in surgical settings is one of constant adjustment and readjustment.
Discussion The findings of this study describe the experience of practicing nursing in developing countries as significantly different from that of the developed world. When providing humanitarian aid,
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nurses must work through various moral, ethical, cultural, and language barriers and resource constraints. It is also identified that the experience is enriching and provides professional and personal growth. The findings are congruent with research that has shown humanitarian aid to be multidimensional, relational in nature, and contextually different (Agazio, 2010; Bjerneld et al., 2004; Bjerneld et al., 2006; Drifmeyer & Llewellyn, 2004; Hunt, 2008; MacRae, 2008; Markus & Zwi, 2002; Parfitt, 1999; Zinsli & Smythe, 2009). Factors that affect nurses’ experiences include cultural, political, and economic issues differing across cultures. The study findings show that although humanitarian practice may differ in terms of specialization, nurses rely on professional and ethical codes of practice for adjusting to different contexts and readjusting on return home. Working within different cultural values, limited resources, and linguistic constraints requires nurses to extend roles and responsibilities. This includes an expansion of clinical decision making, teaching and mentorship roles, as well as the capacity for leadership and management. Despite the anxiety related to practicing beyond one’s legislative parameters, the nurses often found within themselves with potential to use innovation in practice. Firsthand experience of life in developing countries, gaps in health services, and the desperate plight of many individuals make it a sobering experience. Yet this is countered by the reward of knowing that one has contributed to a reduction in global ill-health. Additionally, the participants in this study did not report seeking psychological support after humanitarian experience in surgical or war-affected zones as reported by Hearns and Deeny (2007). The authors found that lack of psychological support for aid workers during and post complex emergencies, can result in feelings such as lack of achievement regarding self and mission. The findings of this study clearly demonstrate humanitarian nurses’ ability to adjust to new and challenging situations. Accepting what is important to the recipient nation is a significant and necessary part of the experience. This is consistent with Chang’s (2007) findings that a change of mind-sets and acknowledgement of the equality and difference between cultures assist clinicians toward cultural competence.
Limitations of the Study The small number (n = 4) of participants in this study limits the generalizability of findings to other contexts. A further limitation relates to the level of specialty; in this case, pediatric, general intensive care and surgical nursing in war zones. Furthermore, the mixture of long-term and short-term mission experience may have affected the extent to which the nurses were affected by the phenomenon of providing humanitarian aid.
Recommendations Nurses who provide humanitarian aid in developing countries require clinical expertise in addition to other significant
attributes such as being, innovative, flexible, and adaptable to the constraints of the recipient practice environment. These findings have implications for the recruiting organizations preparing nurses for humanitarian work. Preparation must include an emphasis on the contextual issues/cultural issues pertinent to nursing in specific humanitarian settings. The finding of this study also support mentorship by more experienced nurses in the provision of humanitarian aid (Bjerneld et al., 2004; Frossard & Bojarska, 2007; Hunt, 2008). Larger studies and use of mixed-method approaches are needed to further the understanding of effective provision of humanitarian aid within developing countries.
Summary The phenomenon of providing humanitarian aid has illuminated some of the contextual differences relating to practice, anxiety related to the environment, being misunderstood, and last of adjustment to life back home. Nursing education needs to include cultural sensitivity and safety, related to cultural differences at national and local levels, including global issues in health care. Courses that address global health issues and preparation for greater cultural diversity would benefit nurses at all levels and in all areas of practice. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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research-article2014
TCNXXX10.1177/1043659614536585Journal of Transcultural NursingLal and Spence
Article
Humanitarian Nursing in Developing Countries: A Phenomenological Analysis
Journal of Transcultural Nursing 1–7 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614536585 tcn.sagepub.com
Shane Lal, RGON, BN, MHSc1 and Deb Spence, RN, RM, PhD1
Abstract Background: Surgical nursing within humanitarian contexts is complex, sporadically described in literature and little understood. Aim: To achieve a deeper understanding of the lived experience of New Zealand nurses providing humanitarian aid within surgical settings and war zones in developing countries. Method: In-depth conversational interviews were undertaken with four New Zealand nurses whose humanitarian experience lay in general surgical, military, and intensive care settings. A qualitative descriptive method as described by Sandelowski, informed by van Manen’s phenomenology in terms of analysis, was used. Results: Specialized knowledge and nursing expertise are recognized to be essential but not sufficient for humanitarian work. Understanding local cultures contributes to positive feelings about work effectiveness. Themes included feeling anxious and misunderstood, practicing differently, and adjusting to life back home. Discussion: This study highlights the need to better prepare nurses who volunteer for humanitarian work, with implications for recruiting organizations, educators, and clinicians. Keywords international educational experiences, qualitative research, cardiovascular, medical/surgical, military
Introduction Travel to exotic and war destinations for humanitarian work seems exciting and heroic to many health care professionals, including nurses. These ventures provide personal and professional growth. They also offer insight into the cultural, political, and socioeconomic climate of nations whose health care provision differs vastly from that of the developed world. However, nurses’ work in developing zones is accompanied by concerns for the rationale behind the delivery of appropriate care to the recipients. The fact that cultural and ethical issues encountered in humanitarian work often clash with the personal and professional values of workers from foreign nations has been highlighted by Hunt (2008). Additionally, questions pertaining to humanitarian work effectiveness and sustainability have been raised by Hunt (2011) and Markus and Zwi (2002). There is an increasing demand for effective global health service development (Bunyavanich & Walkup, 2001; McQueen et al., 2010). Despite inadequate information available on the needs of surgical services in developing countries, humanitarian interventions continue to be provided to improvised communities (McQueen et al., 2010). Good intentions and professional and moral obligation to assist people in need are cited as the main reasons for participating in the provision of such care (Pezzella, 2006; Sommers-Flanagan, 2007; Tschudin & Schmitz, 2003). A wide range of attributes have been identified mostly in relation to those working in military operations or postwar situations, primary health care, and emergency
situations (Agazio, 2010; Bjerneld, Lindmark, McSpadden, & Garrett, 2006). Relatively little research has been published of nurses’ work in surgical contexts. Therefore, the aim of this study was to achieve a deeper understanding of the lived experience of New Zealand nurses providing humanitarian aid within surgical settings in developing countries. For the purpose of this study, the term humanitarian work or humanitarian aid, used interchangeably in this study, is defined as volunteering personal and professional skills as well as time to assist populations in war zones and resource-poor countries.
Review of Literature Factors recognized to generate the need for humanitarian aid include the effects of economic, social, and environmental impact on developing nations (Pezzella, 2006). The World Health Organization, the United Nations, the World Bank, government organizations, nongovernment organizations, and charitable bodies such as the International Committee of the Red Cross and faith-based organizations are agencies whose contributions and health initiatives have made a positive difference to millions of people (Belcher & DeForge, 1
Auckland University of Technology, Auckland, New Zealand
Corresponding Author: Shane Lal, 8 Warwick Street, Western Springs, Auckland 1010, New Zealand. Email: [email protected]
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2007; Bunyavanich & Walkup, 2001; Dufour, De Geoffroy, Maury, & Grunewald, 2004; Frossard & Bojarska, 2007; Jayasinghe, 2009; Pezzella, 2006; Ruger, 2005). Recent research relating to humanitarian work has focused on work effectiveness, sustainability of services, and imposition of Western values on developing nations (Thieren, 2007). There are now principles and codes of conduct for humanitarian workers involved in the developing world (International Federation of Red Cross and Red Crescent Societies, 1995; Sommers-Flanagan, 2007; Thieren, 2007). However, the transferability of codes and principles relevant in Western health care to developing countries remains problematic (Bell & Carens, 2004; Hunt, 2008; Markus & Zwi, 2002). Ideally, the delivery of all humanitarian work should be bound by standards and protocols that respect the infrastructure and culture of the recipient nation (Dufour et al., 2004; Pezzella, 2006). However, Marcus and Zwi (2002) have clearly demonstrated the dominance of foreign teams on institutional arrangements and structures of local services. This study demonstrated the significance of the need for partnership in humanitarian work. Nurses contribute to government organizations, such as the military and naval forces. These organizations facilitate short- and long-term humanitarian missions (New Zealand Red Cross, 2009) and adhere strongly to the World Health Organization-UNICEF Alma-Ata principles to attain health outcomes acceptable by the impoverished communities (Frossard & Bojarska, 2007; Thieren, 2007). The complex nature of delivering humanitarian aid has been articulated by numerous authors (MacRae, 2008; Markus & Zwi, 2002; Parfitt, 1999; Pezzella, 2006; Pupavac, 2004; Walsh, 2004; Zinsli & Smythe, 2009). Working with awareness of local resources and in collaboration with local teams has been identified as empowering and promoting independence in local communities (Heck, Bazemore, & Diller, 2007; Parfitt, 1999; Walsh, 2004). Parfitt (1999) found that “power” is utilized by nurses in practice both to empower and/or to increase dependence on the services provided by the donor nations, thus overriding the humanistic values of beneficence, which often initially attract nurse to humanitarian work. Bell and Carens (2004) similarly reported that Western humanitarian workers and organizations may not be familiar with unexpected complications in developing countries or know how to deal with the subtle behavioral nuances of people with different cultural and political systems. Researchers who have explored cross-cultural nursing experiences more generally assert that recognizing the power differentials inherent in health service delivery is essential for effective clinical practice (Spence, 2001). Furthermore, the well-known cultural theorist Madeleine Leininger in her seminal ethnographic work of the Gadsup culture in the highlands of Papua New Guinea argued that “very serious ethical and moral issues can rise if health care professionals
make assumptions and decisions based on western child and adult rearing practices that do not fit non-Western or under developed people” (Leininger, 2002, p. 217). Phenomenological research undertaken by Hunt (2008) sought to gain deeper understanding of the ethical issues and moral reasoning employed by Canadian health care professionals working in developing countries. Participants were reported to struggle to respect local customs and beliefs that clashed with their own values. Differing understandings of health, illness and death created dilemmas and barriers to providing care appropriate to the locals (Hunt, 2008). A more recent qualitative study of doctors, nurses, midwives, and human resource and field workers by Hunt (2010) reports that humanitarian work is a morally complex activity that requires preparedness, support, and strong motivation. This is further complicated when the increasing cultural diversity of humanitarian workers adds to the varied and complex nature of ethical issues and their subsequent resolution (Hunt, 2008). An exploration of perception of humanitarian work highlighted preparedness, professional competence, and previous experience of humanitarian work as key factors to achieving better outcomes (Bjerneld, Lindmark, Diskett, & Garrett, 2004). A later study by Bjerneld et al. (2006) reported a strong desire to contribute for reasons of personal development and satisfaction. Both studies also highlighted health care professionals’ concerns of personal security and professional competence for undertaking such work. However, the motivational needs of health care professionals to engage in humanitarian work in these study findings present a strongly Western perspective. New Zealand, despite its small size, has always played a significant role in humanitarian missions (Caughley, 2001). An exploration of New Zealand nurses’ experience of humanitarian work reported by Zinsli and Smythe (2009) revealed concerns about personal security and differences in culture and practices of people. Paradoxically, the findings also suggested that it was the New Zealand nurses’ ability to cope with a variety of challenging situations that drew them to volunteer again. Army nurses’ experiences are similar to those experienced by many nonmilitary humanitarian missions (Agazio, 2010; Bjerneld et al., 2006; Crawford & Harper, 2001; Hunt, 2008, 2010; Zinsli & Smythe, 2009). Agazio (2010) reports that army nurses practicing in military humanitarian missions require specialized skills and personal adaptation under austere conditions. Preparation in relation to ethical, moral, and cultural conflict experiences has been recognized by Bjerneld et al. (2004), Hunt (2008, 2010), and Parfitt (1999). Although the focus of this literature search was nurses’ experience, the studies reviewed had both a nursing and a combined health care professional focus. The literature reveals an emphasis on concepts such as power, ethics, values, and motivation and health care professionals’ perception of humanitarian aid work. It provides insight into the overlapping issues of ethical and moral dilemmas, cultural difference, and
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Lal and Spence power differentials in the context of primary care, hospitals, emergency settings, and postwar conflict zones.
Research Approach A qualitative descriptive approach as described by Sandelowski (2000) with thematic analysis informed by van Manen (1997) was used to achieve a deeper understanding of this complex phenomenon. The study was approved by and met requirements of the Auckland University of Technology Ethics Committee. Purposive sampling was used to recruit nurses who had experienced humanitarian nursing within different surgical contexts in developing countries. The four participants comprised two male and two female nurses. Their ages ranged from late 20s to mid-forties. The participants’ reported a total contribution of 18 years’ humanitarian work. Areas of work experience included pediatric cardiac intensive care, general intensive care nursing, and military nursing. They had undertaken between one and nine missions. The duration of missions lasted from 2 weeks up to 9 months. Participants’ real names were replaced with pseudonyms, to maintain anonymity in the reporting of data excerpts. Data were collected via digital voice recorder, in one faceto-face interview session with individual participants. The interview questions focused on their experience of humanitarian missions and commenced with unstructured, openended questions: “How did you become involved in humanitarian work”? “Can you describe a recent humanitarian work experience as in much detail as possible?” “What were your hopes and fears”? Follow-up questions were based on data that the participants were providing and its relevance to the research question. The use of a nod, an “mm,” or a pause allowed time for thinking and encouraged the participants to provide rich descriptions of their experience (Kvale & Brinkmann, 2009). Interviews lasted 40 to 90 minutes and the audio-recorded interviews were immediately transcribed by one transcriber, who completed a confidentiality declaration.
Interpretive Analysis The “consistent selective reading approach” outlined by van Manen (1997, p. 93) required looking for sentences, statements, and phrases that seemed particularly revealing of the experience of working in developing countries. The process involved isolating structures of meaning and removing extraneous aspects of the stories (van Manen, 1997). The dialectical nature of interpretive process required the researcher to move between the parts and the whole text to construct successive or multiple layers of meanings while maintaining a strong focus and orientation to the research question. During analysis, personal experience as a humanitarian nurse worker enabled insight into participants’ humanitarian experience. The author’s own experiences of humanitarian work had been articulated prior to commencing data collection and
therefore the author needed to be aware of ways these were influencing the analysis. Thus, supervisor guidance was regularly sought during the processes of thinking, selecting the most appropriate excerpts, writing and rewriting interpretations, and formulating tentative themes. These processes eventually culminated in a thematic description of the phenomenon as a whole.
Findings Close examination of nurse’s accounts revealed the following sequential themes: 1. Feeling anxious, worrying, and being misunderstood 2. Practicing differently 3. Adjusting to life back home Pervasive throughout was the overarching theme of Adjusting and Readjusting. The first theme describes nurses’ perceptions of humanitarian work, arrival into the recipient country, and adaptation with the donor and recipient teams. It reveals the precarious position in which the nurses find themselves as they adjust to the complexities and issues encountered within the initial phase of humanitarian aid work. The second theme captured the positive responses to challenges of practicing in less affluent nations where there are diverse ethical, moral, and professional challenges. The final theme highlights a realization of the disparities in health care and human suffering and the time needed to readjust to work and life in one’s home country alongside continued commitment to humanitarian nursing.
Feeling Anxious, Worrying, and Being Misunderstood Nurses experience feelings of anxiety, trying to fit into the team, being misunderstood, working to gain trust, and worrying about safety, although time constraints hasten the ability to find a place in the team. This is more evident in nurses on a first mission than those who had previous experience of humanitarian work. The teams consist of people from different countries, each person with his or her with own specific culture, language, and practice expertise. Finding one’s place quickly within the team provided incentive and drive for work performance. One participant described her first meeting with the team as their work began: You basically bounce ideas around to get a feel for how nurses work. The team works surprisingly well with each other and I think that’s partly because everybody is in the same situation. Everybody is new, nobody knows anyone. You basically have to place your trust [in them] quite quickly. (Kate)
Understanding teamwork requirements and others’ expertise is vital for effective collaboration as work commences.
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Common to all is feeling that there is work to be accomplished. Those who had previously worked in humanitarian missions knew that having a common purpose was critical but also knew personalities could disrupt teamwork. I think as long as everyone keeps it in mind what they’re there for, it worked well. When people’s individual egos get in the way, then it breaks down and things don’t work so well. (Nancy)
In addition to being anxious and worried about his or her specific place in the visiting team, the nurses also take on leadership roles, guiding and mentoring local colleagues. Adjusting to these supportive leadership roles is also anxiety producing. Faced with barriers of language, cultural difference, and lack of resources, the nurses feel a strong sense of respect for the host nation’s space and values, believing it morally wrong to provide advice without knowing what was important to the local team. One has to know and respect the other culture before stepping in, and not knowing how much English they would be speaking made it harder. This was part of the problem. It was either lack of equipment, or lack knowledge. . . . I tried to stay back and act as a mentor rather than taking over. The local nurses became colleagues very quickly but in the end, they turn to you for support, which is quite intimidating. (Kate)
In addition to the ongoing practice challenges, nurses on lengthy humanitarian missions lasting up to 9 months also faced personal adjustments relating to their living conditions. Prolonged time spent in close proximity with team members affects them both personally and professionally. We lived so closely, almost out of each other’s pockets for 9 months. Sometimes there was friction, but you just couldn’t just go home to a whisky. It’s a long [time] away from home. It became harder to maintain that enthusiasm as the time went on . . . But we still had to go on for we knew that it was a finite sort of situation . . . (Paul)
Other challenges inherent in humanitarian nursing are revealed through experiencing distrust and suspicion, especially from authorities in countries where tension and hostilities exist. This challenges professional values, codes of conduct, and the core value of caring inherent in nursing practice. When I arrived I got separated out, interrogated and searched. I felt nothing but hostility from immigration. I didn’t understand—how anyone could think that people are inferior because of their race or religion, sexuality, or whatever. I struggled with that. (Nancy)
Another participant was outraged by the tensions and misunderstandings associated with his humanitarian efforts: There was rumour circulating that the ship [Mercy Ship] was only there to steal organs from people—we were being accused
of organ theft! . . . their organs taken and sold overseas, this were utter rubbish! You try to do a good thing and there are always people who hate good things being done. (Mike)
Although this lack of trust was disturbing, the nurses worked to gain trust at the ground level with local health care professionals and patients. Those with previous humanitarian experience knew that building relationships, trust, and acceptance with the locals was achieved through showing a genuine commitment through successive returns to the same place. Humanitarian nursing in areas by war requires understanding and being patient with the local people, who are affected physiologically and psychologically. It took a little while to gain their trust but when they figured out that we were there to help, they were queuing up outside the compound . . . (Paul)
The nurses understand the importance of being sensitive to the needs of the people in any context. Patience, reassurance, and time were essential factors in gaining trust of the local people. Concerns about safety and security were commonly experienced, and staying close to team members was a way of coping with potentially life-threatening situations. Knowledge of continuing political unrest and the witnessing of some horrific scenes required them to be “extra vigilant and on guard at all times.” There was the threat that we could be killed by militia. It is an eerie feeling, it gives you goose bumps. You had to have someone with you at all times and carry your weapon, even as a nurse. . . . You had to be extra vigilant . . . (Paul)
Practicing Differently Practice differentials experienced by nurses related predominantly to resource constraint, lack of local expertise, and different clinical practices. Sensitivity to local limitations and a willingness to adapt and work within the local ways were evident in the nurses’ accounts. On the first trip, we tried until we were blue in the face to emphasize how important it was to do mouth care . . . it wasn’t going to happen no matter how many times we said—it just wasn’t a priority. Getting the child through the surgery and getting them home safely is much more important [to them]. (Nancy)
Although practicing challenged personal and professional values, the nurses adjusted their practice to respect local ways of thinking and different worldviews. In their environment families don’t get to visit. We couldn’t change their policies and say, “You must do family-centered care.” That takes a bit of getting your head around—yes, it’s
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Lal and Spence different to us but it doesn’t make them wrong and it doesn’t make us right. (Nancy)
Human and technical resource constraints were often problematic. The complexity of surgical intervention and intensive postoperative care required reliable equipment and clinical decision making that was different from their practice at home. The blood gas machine had broken; we couldn’t get magnesium at all. The ventilation wasn’t great. This child was off-color, the blood pressure was dropping and there was no one to turn to. . . .It often didn’t go as anticipated. There were a lot of complications with the kids. (Kate)
Linguistic barriers, levels of collegial support, and a more demanding nurse-to-patient ratio compounded these challenges as Mike explains, You’d be looking after 3-4 or 5 patients [in intensive care] so you find yourself running from one thing to next and getting used to. . . . different languages . . . it was not the same as I was used to New Zealand . . . (Mike)
There were also challenges to collaborative decision making and working within a scope beyond those legally required in their home countries (Nursing Council of New Zealand, 2007). The experience of providing humanitarian work to people in developing countries helps advance nurses personally and professionally. It develops an understanding of political and economic differences and numerous opportunities for problem solving. [The] huge range of experiences makes you a bit more tolerant of other people and other cultures. It makes me appreciate [resources]. I’m more tolerant person and more aware that there’s more than one way of solving an issue or a problem. When you’ve got limited resources, you learn to be ingenious, a bit more lateral thinking. . . . it has been really valuable to me personally and professionally. (Paul)
However, along with the many unanticipated and morally challenging situations encountered in humanitarian work, the experience overall is rewarding in a profoundly different way from nursing in their own country. Women with obstetric fistulas are ostracized by their communities and families, it’s pretty cruel. After their surgery, they’d have dress ceremonies, a passing-out parade for patients and they leave the ship with big smiles on their faces, they are given a new lease on life. Providing this sort of health care is enriching and satisfying. (Mike)
Nurses providing humanitarian service have often experienced the unselfish and overwhelming generosity of those who have very little: They are so welcoming and friendly . . . so open despite being beaten back time and time again. They will welcome you with
open arms every single time that you visit. . . . They had no money but when you arrived at their house, they would run down the road and come back with a bottle of carbonated soft drink that might have cost them 6-months wages just to be hospitable to you and to show friendship. It was just amazing . . . just amazing (Nancy)
Adjusting to Life Back Home Readjusting, following return from foreign humanitarian work, takes time. The nurses’ frustrations continue as they experience the lack of appreciation by nursing colleagues of resources and their taken-for-granted attitudes to New Zealand services. The wide economic disparities that affect the health care and people in developing countries are a constant reminder to the nurses in their initial phase of readjustment. The longer you’re away; the more you get soaked in the local experience and the local environment and the issues of that environment. … . . You can forget what it’s like to be much better off; just as I got absorbed in the way it was over there. . . [Here] you can use another piece of gauze or another pair of gloves or throw something away because it fell on the floor. You know there are plenty more in the cupboard. (Mike)
Returning to their technically advanced environments is hard because the memories of having to initially adjust to vastly different priorities and less than ideal ongoing treatment because of insufficient time and resources remain vivid. You can’t do complex surgery that will take three [stage] repairs over time because the patient’s family can’t afford medication. They might never get back there [home] again. . . . It’s really hard when you come from a society where you can throw money around into everything. (Nancy)
Adjusting and Readjusting In an overall sense, the experience of providing humanitarian aid in developing countries is one of recognizing the need to change one’s practice to align with the priorities, values, and resources within the local community. This often means accepting a focus on survival, for example, rather than providing for hygiene needs such as mouth care. It also means feeling anxious and scared about extending one’s practice beyond the level previously practiced at home. Significantly, it is an experience of feeling rewarded in ways not previously imagined. The nurse’s practice is less constrained than in his/her own country, and this release of potential is what draws them to return. The experience of humanitarian nursing in surgical settings is one of constant adjustment and readjustment.
Discussion The findings of this study describe the experience of practicing nursing in developing countries as significantly different from that of the developed world. When providing humanitarian aid,
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nurses must work through various moral, ethical, cultural, and language barriers and resource constraints. It is also identified that the experience is enriching and provides professional and personal growth. The findings are congruent with research that has shown humanitarian aid to be multidimensional, relational in nature, and contextually different (Agazio, 2010; Bjerneld et al., 2004; Bjerneld et al., 2006; Drifmeyer & Llewellyn, 2004; Hunt, 2008; MacRae, 2008; Markus & Zwi, 2002; Parfitt, 1999; Zinsli & Smythe, 2009). Factors that affect nurses’ experiences include cultural, political, and economic issues differing across cultures. The study findings show that although humanitarian practice may differ in terms of specialization, nurses rely on professional and ethical codes of practice for adjusting to different contexts and readjusting on return home. Working within different cultural values, limited resources, and linguistic constraints requires nurses to extend roles and responsibilities. This includes an expansion of clinical decision making, teaching and mentorship roles, as well as the capacity for leadership and management. Despite the anxiety related to practicing beyond one’s legislative parameters, the nurses often found within themselves with potential to use innovation in practice. Firsthand experience of life in developing countries, gaps in health services, and the desperate plight of many individuals make it a sobering experience. Yet this is countered by the reward of knowing that one has contributed to a reduction in global ill-health. Additionally, the participants in this study did not report seeking psychological support after humanitarian experience in surgical or war-affected zones as reported by Hearns and Deeny (2007). The authors found that lack of psychological support for aid workers during and post complex emergencies, can result in feelings such as lack of achievement regarding self and mission. The findings of this study clearly demonstrate humanitarian nurses’ ability to adjust to new and challenging situations. Accepting what is important to the recipient nation is a significant and necessary part of the experience. This is consistent with Chang’s (2007) findings that a change of mind-sets and acknowledgement of the equality and difference between cultures assist clinicians toward cultural competence.
Limitations of the Study The small number (n = 4) of participants in this study limits the generalizability of findings to other contexts. A further limitation relates to the level of specialty; in this case, pediatric, general intensive care and surgical nursing in war zones. Furthermore, the mixture of long-term and short-term mission experience may have affected the extent to which the nurses were affected by the phenomenon of providing humanitarian aid.
Recommendations Nurses who provide humanitarian aid in developing countries require clinical expertise in addition to other significant
attributes such as being, innovative, flexible, and adaptable to the constraints of the recipient practice environment. These findings have implications for the recruiting organizations preparing nurses for humanitarian work. Preparation must include an emphasis on the contextual issues/cultural issues pertinent to nursing in specific humanitarian settings. The finding of this study also support mentorship by more experienced nurses in the provision of humanitarian aid (Bjerneld et al., 2004; Frossard & Bojarska, 2007; Hunt, 2008). Larger studies and use of mixed-method approaches are needed to further the understanding of effective provision of humanitarian aid within developing countries.
Summary The phenomenon of providing humanitarian aid has illuminated some of the contextual differences relating to practice, anxiety related to the environment, being misunderstood, and last of adjustment to life back home. Nursing education needs to include cultural sensitivity and safety, related to cultural differences at national and local levels, including global issues in health care. Courses that address global health issues and preparation for greater cultural diversity would benefit nurses at all levels and in all areas of practice. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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