Highfield, Martha E.F.
A few years ago I began considering serving on short-term, nursing mission trips to the Nigerian Christian Hospital (NCH) in the rural, rain forests of West Africa. NCH was an obvious choice; I'd spent time there as a child with my medical missionary parents. I was excited about returning as a nurse and an educator. Family commitments kept me from longer trips, but short overseas commitments seemed doable.
Still, as I prepared, I wondered, "What could I do in 2 weeks?" "Was I wasting time and resources when the money could be used to feed the poor, buy medicines, or pay local healthcare workers?" "What did I hope to achieve?" "How should I prepare?"
I knew the trip would be demanding. No other western nurse was going, and no formal educational preparation was offered prior to the trip. Diseases, treatments, and Nigerian-style nursing would be unfamiliar. I'd deal with a tropical climate, jet lag, and different routines in a different culture. I knew the personnel at NCH see hundreds of outpatients weekly, admit more patients than the 100 beds will hold, and have limited equipment, inadequate supplies, and imperfect communication—including phones that ring to the wrong number.
As I considered these challenges, I found encouragement in words Jesus spoke in defense of a woman who anointed him with expensive perfume: "She did what she could" (Mark 14:8, NIV). Others criticized her efforts as wasteful, but Jesus called what she did "a beautiful thing" (Mark 14:6). His accepting of her best efforts gave me confidence he would accept my own best (if imperfect) efforts to honor him.
Armed with this reassurance I decided to proceed, trusting that even my smallest efforts would be accepted. As I prepared, traveled, and returned, I learned much.
Although I had the advantage of spending part of my childhood in Nigeria with medical missionary parents, I knew I would be challenged to apply my past knowledge of Nigeria and its peoples in new ways.
Because "Chance favors only the prepared mind" (Louis Pasteur, as cited in Wikiquote, 2008)—and so does mission work—I armed myself with updated information, took preventive health measures, identified my strengths, and set flexible goals. If I were going to give my best spiritual and nursing efforts, I needed to be ready with practical information and prayer.
Gather information. Over several months I searched for information about the setting, the team going with me, the staff in Nigeria, the culture, and common patient foods, diseases, needs, and treatments. I talked to short- and long-term NCH missionaries, and read print and online sources. I communicated with travel agents, the American Embassy, the mission team leader, and International Health Care Foundation (IHCF) under whose auspices I was going.
Through NCH missionaries I learned tidbits like: use up supplies in storage and replace them or rats or mold may get them before we do; younger nurses are eager to learn; nursing staff need to learn more about postoperative mobility, infection control, and documentation issues; and computer connections and phone service are available but limited (A. Crump, P. Wilson, & M. Worsham, personal communications, January 2002). Such information gave me direction in planning appropriate teaching.
I consulted—and wished I had taken with me—a first-aid manual and books relevant to healthcare in developing world settings, such as Where There Is No Doctor (Werner, Thuman, & Maxwell, 2007) or Where Women Have No Doctor (Burns, Lovich, Maxwell, & Shapiro, 2006). These and similar resource books are available through free downloads or paperback from http://www.hesperian.org/index.php.
An especially helpful source in better understanding Nigerian culture was African Friends and Money Matters (Maranz, 2001). Maranz addresses topics such as why friends appear unannounced at meal time, why locals ask constantly for belongings, why Africans may use money innocently in ways we consider dishonest, why they may not answer our questions, and other nuances of African humor, gender roles, politics, etiquette, and economy. I was fortunate to have books written by missionaries to NCH (Farrar, 2002; Farrar & Hood, 2003) that provided site-specific information about the physical, cultural, and spiritual environment.
The Internet provided a rich resource of epidemiological and travel data. The interactive site Globalis (Global Virtual University, n.d.) displays sociodemographic and health data by country. I learned the extent of Nigerians' limited access to clean drinking water, that infant mortality is 100 for every 1,000 births, and that life expectancy has decreased from 55 to 50 possibly because of HIV/AIDS.
An online search for teaching resources turned up the International Federation of Infection Control (2007) educational manual for developing countries. I printed the manual and took it with me to leave at NCH. The Centers for Disease Control and Prevention (CDC) (2009) cited facts about infectious diseases and travel health in Nigeria; and the World Health Organization (2009) site offered standards of care and health information by country and disease. Regularly updated travel warnings by country continue on the U.S. Department of State Bureau of Consular Affairs Web page (2009).
Mastering a new language was not necessary, although greeting locals in their own language was important in this relationship-oriented culture. The King's (British) English is the official, national language in Nigeria, and translators abound where 510 tribal languages exist side-by-side (Gordon, 2005). Our team could not assume that speaking American English meant the same thing. For example, in Nigeria if you say you will "consider" something it means you intend to do it, or to "chop" means to eat. I would have to listen and speak carefully!
Attend to health issues. Health preparation included getting travel immunizations and malaria medicine. Sometimes these services are available in school health centers or public health departments. I bought travel insurance that covered overseas emergencies and medical evacuation, and I packed an extra pair of glasses and my medicines in my carry-on bag. I inquired about room and board arrangements. For those with special health needs, consulting in advance with a U.S. care provider about travel restrictions or unique equipment or food needs might make a seemingly impossible trip, possible.
Identify strengths. I planned work that fit with my personal skills and resources. I was the nurse on a team that included a surgeon, local nursing staff, missionary wives, Nigerian evangelists, and others. We would work together trusting God who provided "some to be evangelists, and some to be pastors and teachers" (Ephesians 4:11), and some to be healthcare providers and repairmen.
At NCH the indigenous hospital chaplains were best positioned culturally and linguistically to meet the spiritual needs of those who came. The surgeon would do surgery. I would bring donated nursing textbooks, teach nurses and patients, and assist the surgeon and local staff. The "handyman" would repair equipment and plumb hot water, and the surgeon's wife would teach health and children's Bible classes. Each of us prepared to apply our own skills as a living demonstration of God's love.
Set flexible goals. In setting goals, I took my cue from Ben Franklin's proverb that "little strokes fell great oaks" (n.d./1986, p. 19). Setting limited goals helped in two ways. First, goals focused my activities so that I didn't try to do everything. Second, realistic goals protected me from the potential frustration of feeling I had accomplished nothing.
I started goal-setting by brainstorming with experienced missionaries about what could actually be accomplished in the time I had. One short-term U.S. nurse e-mailed this insightful summary of her NCH experience:
There is so much to learn about the culture and their way of seeing the world. I listened to the team members who'd been going for some time, and tried to learn all I could. I decided that I could do my best work by modeling care. I worked in the OR and managed to imprint my ways a tiny bit on their world...like counting sponges and sharps. - (M. Worsham, personal communication, January 8, 2002)
Like that nurse, I felt a bit lost and hoped after arrival I'd identify my own "best work" at NCH. Through prayer and reflection, I set three goals: (a) learn, (b) accomplish one task, and (c) teach my accompanying teenage son about the work at NCH. I did not know what I would learn, what the one task would be, or how I would integrate my nonmedically oriented teenager into the work. I was prepared for my one accomplishment to be any temporary or permanent project that got done because I was there, but that might be undone as soon as I left.
Investigate licensure requirements. I was going to Nigeria as an invited visitor, licensed only in the United States; I would assist Nigerian licensed staff only as requested and as an unpaid volunteer; and I would not take jobs away from Nigerians. Our team was invited through an official letter from a Nigerian physician, and I carried this letter and my U.S. registered nurse license with me.
My planning for licensure matters was guided by input from the mission team leader and IHCF, who had worked in Nigeria for decades. In our case short-term trips could be completed as nurse visitors. Were I going for longer than 4 to 6 weeks, I might have come in under a work quota allotted to our organization by the overseas government. Such quotas specify positions that may be filled by foreign (U.S.) nurses and the work they may do. Unless you are going independently on your own, I recommend you work with overseas governments through your experienced, sponsoring organization.
IN THE FIELD
Use goals to guide service. One 2-day flight schedule, one 2-hour bumpy drive, one too-short nap, and I found myself at NCH. My goals—to learn, accomplish one thing, and involve my son—kept my activities focused. Particularly helpful was the goal to learn, because it made every experience meaningful.
I started by learning about nursing at NCH. I attended staff meetings, talked with nurses, rounded with the nurse-in-charge, reviewed charts, and rounded with the surgeon. Second, instead of accomplishing only one task—bringing donated textbooks and medical supplies—I found a plethora of opportunities: cleaning the Sahara-dusted suture shelves and hanging a cloth cover to protect them, assessing patients in a nearby village clinic (Figure 1), developing a worksheet to facilitate surgery schedules, teaching moms about HIV/AIDS during well-baby clinic, lecturing to nursing students at a nearby university, and teaching a ladies Bible class. Finally, my nonmedical teen acted as an orderly, assisted in the operating room, organized sutures, measured refraction of donated glasses (Figure 2), played with children in a nearby orphanage, and served as photographer documenting our work.
What did I learn about goals? Always include the goal to learn. Consider other goals as flexible, especially if this is a first trip. Be ready to rework your plans to fit what you find. Even missionaries who go yearly report they never return to exactly the same place they left.
No matter how reasonable your goals, you may spend days assessing where you fit in. If you find yourself in this position, watch, listen, and shadow others. Be ready to find and fill the gaps.
Remember your guest status. The local missionaries and staff at NCH were hospitable and encouraging. They organized our room and board, provided e-mail access, took us to local markets, and advised on safety and other practical matters. We had the opportunity to encourage them by bringing them hard-to-get items, celebrating with them, and recognizing their work.
How can you be a good guest? Ask in advance what personal gifts you might bring for the missionaries, such as (in our case) chocolate chips, chili mix, Kool-aid, or candied ginger. While on the field, ask about their day-to-day work and how you can help. Recognize their achievements. Take an interest in their interests. Listen.
Always remember that you are a guest on the mission field. Consider how you might feel if someone moved in next door for 2 weeks "to help" you with your work, particularly if that assistance involved using your car, computer, food, home, and time. This is the possible scenario created by short-term workers if we are oblivious to the ongoing work of resident missionaries and staff. While local missionaries may be gracious, our efforts could wreak havoc on theirs.
You also are a guest of the country that you visit. You are subject to local laws, customs, and dangers, so heed advice from those who live there. If told that women dress only in a particular way, conform. If they tell you not to go to town at night or not to wear jewelry, act accordingly. You have chosen to be part of a foreign and a mission culture. Honor both.
Be flexible. I found the proverb, "Blessed are the flexible for they shall not break," one of the first rules of missionary life. Significant differences between western and Nigerian perception of time and cultural norms tested our tensile strength. Heavy rains, power outages, and road disrepair created transportation and communication issues. Local workers were unfamiliar with donated, high-tech, equipment. Electricity was sporadic.
In addition to these daily adventures, locals asked us for anything and everything. I had come to NCH with the idea that I was there to improve local physical and spiritual health, but when I arrived I was asked for "bics" [pens], hand lotion, the scrubs I was wearing, information on how to come to America, money, photographs, and so on. The requests were pervasive and exhausting.
In this matter, Maranz's (2001) counsel was especially helpful. Work to see the constant requests not as obstacles, but as opportunities to develop Christian relationships with those you wish to serve. Many requests are actually indirect compliments. Friendly denial creates neither surprise nor offense among those asking. Maranz's suggestions—"appear to take the request seriously, fend off the request with a polite excuse as to why it will not be granted. And... [when possible joke about] it in a clever way" (p. 81)... gave me a culturally appropriate way to build relationships.
A request, especially for personal possessions, may be a compliment. Prepare in advance to give friendly, smiling responses such as, you "will give them your shirt when ‘it has a little brother’ [i.e., when you have another], ‘Not today,’ ‘If I give it to you, what will I have left?’" (Maranz, 2001, p. 81) or "This is not mine to give away" when true. I saw otherwise compassionate missionaries lose their tempers when they felt besieged by constant demands; the result was embarrassment and damaged relationships.
Recognize that time delays are not a sign of disrespect. Relax and move on. Observe what starts at the stated hour and what does not.
Learn. Deming's comment, "Learning is not compulsory... neither is survival," (as cited in Thinkexist.com, 1999–2006) could have been written about missionaries. Each thing I learned better prepared me for my next trip.
Through journal keeping, I recorded not only the facts of daily life on the field, but my met and unmet expectations, feelings, and reactions. I kept lists, and I tried to reflect daily. My son kept a journal, and as an artist he included numerous sketches.
My written narratives helped me explain NCH experiences to others. In rereading them I am reminded that Nigeria is a culture of personal relationships, so I should greet everyone, ask about their families, take small gifts, and be prepared to receive visitors in the evenings. I see that healthcare at NCH is reactive not proactive, as illustrated in not making the postoperative bed until the patient returns to the ward—perhaps because life there is more fragile. I find in my narratives that palliative surgery is effective in reducing cancer-related disfiguration, pain, and odor when curative therapies are a world away. I discover that healthcare at NCH is more like early 20th than early 21st century care—Nigerians more often die quickly from infectious diseases in their homes where the focus is comfort not cure. I note conversations from staff meetings that illustrate how Nigerian and western nurses often share similar concerns: schedules, pay, benefits, vacations, and education. I realize how happy and encouraging the Nigerian people are despite hardship.
My writing gave me the opportunity to learn from countless, less profound practicalities. The employee parking lot doesn't take much room—99% bicycles. A ceiling fan and breeze-capturing screened windows in the operating room keep the surgical team from sweating onto the sterile field (Figure 3). A cat in the supply room keeps the rats away. Never discontinue an intravenous infusion until the bag is empty because the patient paid for it and wants her money's worth. You can clean almost everything with almost nothing. Write your name on the pair of rubber gloves issued to you, and keep up with them; the next pair may have to come from the U.S. Bibles make great gifts at road blocks. An injection is thought more powerful than any pill. Nurses can keep the patient from falling out of bed if they move his mattress onto the floor. Take care to plug your gadgets into AC adapters with a surge protector and not the local DC outlet.
I planned time in my day to document my experiences. Practice discovery before, during, and after your trip. Begin a journal during preparation. Write (or draw) about why you are going, your actions to get ready, and what you find when you arrive in the field.
If you have computer access you might keep a blog or send e-mail reports to review later. Whether you choose to record experiences orally or in writing, remember that when you first experience something you will see it in a unique way that you may not notice the next time. Take lots of pictures, and write enough so you can later accurately label photos. Important details you thought you would never forget fade quickly, and the only memory may be what you recorded. Having a document to reread later affords time to digest experiences and weave them into a meaningful narrative. An example of the power of even brief notes to capture dramatic experiences is seen in Mancini's (2006) log of her Tsunami relief work.
When we returned home we were bursting with enthusiasm to involve others in the work of NCH and thereby extend mission work. "I wish I could find 200 doctors to bring over," commented my son. We looked for ways to continue our mission work by sharing our experiences.
Involve others. Involving others before we left made it easier to share after we returned. Prior to the trip, I asked church members for donations of Nigerian-requested, unused, prescription eye glasses and pocket calendars, and then I put a brightly wrapped collection box in my church's entry way. In 2 weeks, I received 100 pairs of glasses and almost as many calendars. Those donations have continued without my prompting!
During preparation, my acquaintances, colleagues, and friends asked how they could help. I was ready with a short wish list from resident missionaries: adhesive tape, children's chewable vitamins, Super Glue(r), bandages, sutures, or money I could use to purchase these items.
In Nigeria, I learned that local widows needed money annually to rent farmland and that the NCH mission had a distribution system in place. Funds were needed. The cost to help one widow for a year—the U.S. price of one extra large pizza. When I reported this to my church they began annually sending money for Nigerian widows.
I have had ongoing opportunities to recruit others for short-term missions. I've shared my experiences at mission conferences and served as a guest lecturer on global health issues in community health undergraduate nursing classes. Invariably students and others want to know how to go themselves.
After returning, I was invited to join the U.S. advisory and fund-raising board for NCH. Through that position I am better able to let others know about needs. Recently I set up an online Facebook.com group to discuss the work with interested health professions students from Christian colleges.
Let your enthusiasm show when you tell others about mission efforts. Your excitement—if not full knowledge—about the mission encourages others to participate. Have an informed answer when others ask how they can help, and remember that working with a church or nonprofit allows the opportunity for tax-deductible gifts and provides oversight of donations.
Say thank-you. After returning, I contacted every person and organization that donated to let them know specifically how their gifts helped. I shared first-hand stories about those whose lives were changed. My hope was that everyone involved would understand the value of their continuing efforts. I sent back copies of photos to the Nigerians who let me take and share photographs of them.
I cannot be the final judge of whether I accomplished much or little in Nigeria, but I take comfort in Jesus' words long ago: "She did what she could" (Mark 14:8). I remain confident that God uses both my successes and mistakes to achieve his purposes in the world.