FEATURES

ENCOURAGING SERVICE THROUGH COLLABORATION

Cultural immersion reveals common bonds

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by Susan M. Hinck and Kathryn L. Hope

Quito is “a city of graffiti and gates, pollution and gardens, poverty and beauty, and never-ending movement and noise. I like it here.” That’s how one student from Missouri State University in the United States described the capital of Ecuador. She was one of 14 undergraduate and graduate nursing and premedical students from the school who spent two weeks in Quito as part of a three-credit course to learn about the people, culture and health care of Ecuador. Three faculty members accompanied the students.

In addition to observing health care and learning about the culture, students attended daily Spanish language classes, wrote daily entries in reflective journals and created photo essays related to health in Ecuador. To further enrich their immersion experience, students lived with host families, some of whom did not speak English.

Quito is cool, often misty. At 9,000 feet above sea level and surrounded by active volcanic mountain ranges, it is a dramatic contrast from the rolling Ozark hills of Missouri. Since the economic and political collapse of Ecuador in 2001, the economy has improved, evidenced by new high-rise buildings and an emerging middle class. Still, nearly 70 percent of the city’s approximately 13 million people live in economic poverty (Pan American Health Organization, 2001).

The Ministry of Public Health has established as its priorities provision of food and clean drinking water where most urgently needed, education, and prevention of communicable diseases. In 2001, the Pan American Health Organization (PAHO) reported that nearly half of Ecuador’s children suffered from malnutrition. In rural areas, when children no longer breast-feed, they often eat a diet of rice, potatoes and corn because most fruits, vegetables and meat are sold for cash.

In Quito, we saw children of all ages in the streets selling mints or asking for money. Although education is free, many families are not able to pay for the required books and uniforms. Some children work to bring in a small income to help meet the needs of their family, but there is a growing realization that the future of the country is dependent upon the education of children.

Although the more affluent choose private hospitals, public hospitals serve about 75 percent of the population. During our stay in the country, we observed nursing practice and assisted caregivers in a 700-bed public hospital two mornings a week. Because supplies and equipment are limited, we brought wheelchairs and medical supplies as part of our checked luggage. One student, realizing the need and her part in helping to meet it, said, “I’m glad I hauled that extra suitcase all of these miles now that I know it can make such a difference.”

We were welcomed by hospital personnel and were grateful for the opportunity to learn. The triage area of the emergency department was an atrium lined with chairs, occupied by people of all ages. After admittance, patients were taken to one of four large treatment rooms, with the room assignment based on severity of illness or injury. Nurses quickly gathered essential information and physicians prescribed diagnostic exams, such as X-rays and blood analysis. In addition to filling the emergency department wards, patients waited on gurneys and chairs in hallways until they could be transferred to a unit for further treatment.

Beds in the medical units and ICU were full, with many patients remaining for weeks after surgery for recovery. Because there was not enough linen, patients usually did not have bottom sheets—only a top sheet and a light blanket for warmth. Many patients wore street clothing, because hospital gowns were often not available, and provided their own supplies, such as a toothbrush, soap and toilet paper. Although families provided much of the personal care for patients, waiting rooms were largely bare, often furnished only with plastic chairs, many of them broken.

The Ecuadorian nurses welcomed us to the units and were eager to learn how the nursing care they provided was similar to and different from that of the United States. With their caring, efficient manner and their impeccable dress of white pressed uniforms, caps and polished shoes, the nurses were great role models for the students.

Limited resources in Ecuador inspire nursing creativity. Empty water jugs become sharps containers. Sandbags become traction weights. Although gloves are not worn for routine care, they are adapted as tourniquets when accessing veins for blood draws or placing IV catheters.

PAHO reported that 80 percent of medical equipment used in Ecuador is obsolete and often malfunctioning. This was evidenced by a lack of IV pumps and fetal monitors, and EKG machines were at least 30 years old. Hospital units had a variety of equipment models and ages in use simultaneously.

As a result of what they observed, students learned a new respect for conserving resources. A graduate student who works in an ICU in the United States said: “I learned the importance of being more resourceful. I think of the small things I do at work that I take for granted, like grab a handful of gauze 4 by 4s when I could make do with one or two. I feel I need to be more cognitive of the things I do. The ICU nurses maximized their resources and were very attentive to the patients’ needs.”

Students noticed a difference in authority and autonomy between nurses in Ecuador and nurses in the United States. Ecuadorian nurses on the general medical and surgical units had limited patient contact, and their duties included more documentation and management of the environment. Unlike the United States, nurses on the maternity unit are responsible for cleaning and sterilizing equipment between procedures and surgeries. The nurses we spoke with said they would like to have greater authority and autonomy in their practice and have discussed this with hospital administrators, to no avail.

Wound dressing, urinary catheterization, insertion of gastric tubes and initiation of IV access are performed by medical students and physicians, rather than nurses. A partial explanation for this division of labor may be that Ecuador has more physicians (13.8 per 10,000 population) than nurses (five per 10,000 population), and physicians are required to provide one year of postgraduate public service.

“The nurses were great,” one student commented. “They taught me [Spanish] words and phrases, and I taught them English words. It was awesome how we learned from each other.”

The prison
One morning, we visited a women’s prison. Most of the inmates are expatriates from other countries, jailed for drug trafficking or violent crimes. In Ecuador, children under 12 who have mothers in prison often live with them. Day care is available for babies and toddlers, and older children spend their days in an open courtyard. No schooling is available. Mothers are responsible for obtaining food, diapers, clothing and anything else needed for themselves and their children. Some receive financial support from their family; most do not. Community visiting is allowed three days each week, and women sometimes exchange sex for supplies or money to buy basic necessities.

The prison has three living pavilions, each with a room for cooking and eating. To minimize plumbing, showers and toilets are located in the kitchens. Each of the 8 by 8-foot sleeping rooms off the main corridor has space for three single beds, but not all women can afford a mattress or bedding. The sleeping rooms house three to five women and as many as eight children, along with all their possessions. The mothers usually sleep beneath the beds on the concrete floor. The women and children can enter and leave their pavilions and common areas as they wish.

We were deeply moved by the plight of these women and children. A few churches and charitable organizations provide help, but much more is needed.

Personal discovery
Most students said their reason for taking part in the course was to learn about a different culture and language. For several students, this trip was their first flight and the first time they had traveled outside the United States. The organized, chaperoned trip was a safe beginning to explore new horizons. One student commented in her reflective journal: “It is important to see that there is more than one way to think, act, believe and live. Where I live, there is not a lot of variety or cultural diversity.”

Students were quick to identify what draws humanity together. One wrote: “My values and beliefs are basically the same as the Ecuadorians. We share beliefs in God, helping your fellow man, being nice to others and human rights.”

We expected that the students would build on their learning in prior general education and nursing courses, but the trip expanded their knowledge beyond what could possibly be obtained in a traditional course. The power of the experience was noted in a student’s comment, “In just four hours in the hospital, I learned more about how another country’s nurses treat patients and how things are done than I could ever have learned from a book.”

“Class did not prepare me for this,” another student wrote in her journal. “I knew about cultural diversity, but this experience was far off that, beyond any nursing, sociology or psychology class. It was something you have to experience yourself, because it is hard to put into words, textbooks and pictures. I would not have missed this discovery. It was a new world to me.”

Still another stated: “The experience has changed my attitude and awareness. What makes them different from me? By chance, we were born in different areas.”

In addition to increased understanding of a different culture, students gained a new awareness of themselves and greater self-confidence in responding to unfamiliar settings. “Wow! I can’t believe it is our last day,” said one. “I don’t want to go home! This has been such a great experience. I feel like I lived here. I had a home with a family. I traveled around the city with my friends with no problem. I explored and shopped. I will miss this place a lot.”

Since returning to the United States, students have continued their learning and development of cross-cultural competencies. Some have enrolled in additional Spanish courses. Others have chosen jobs that allow them to serve Spanish-speaking immigrants. An important outcome of our Ecuadorian experience is that we now recognize we are citizens of the world. RNL

Susan M. Hinck, RN, PhD, is associate professor in the Department of Nursing at Missouri State University in Springfield, Mo. Kathryn L. Hope, RN, PhD, is head of the Department of Nursing at the same school.

References

Pan American Health Organization (PAHO). (2001). Profile of the health services system of Ecuador. Retrieved May 2006.