Burger, Jeanne M.
By nearly every significant measure of health and population, conditions in Haiti are distressing—made worse in 2010 by a mass earthquake and outbreak of cholera. The infant mortality rate, a global health indicator, is 77 per 1000 live births for this Caribbean nation. This is 12.6 times higher than the rate in the United States and 15.5 times higher than the rate in Canada. Women of childbearing age give birth to an average of three babies, usually at home (Central Intelligence Agency, 2010). Only 26% of all births in Haiti are attended by a skilled healthcare worker, leaving mothers at risk for complications such as tetanus and other infections, and leading to a maternal mortality ratio of 67 per 10,000 births (World Health Organization [WHO], 2010) (see Table 1 for additional statistics). Natural disasters seem to plague this struggling nation.
One of the most critical factors for improving the health and survival rate of the people in any country is a sufficient and sustainable supply of well-educated nurses (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; WHO, 2006). International experts have recognized that "nurses are the main professional component of the 'front line' staff in most health systems, and their contribution is recognised [sic] as essential to meeting development goals and delivering safe and effective care" (Buchan & Aiken, 2008, p. 3263). Yet the number of nurses and midwives available to care for the Haitian people, with all of their vulnerabilities, is only 1 per 10,000 people, compared to 94 per 10,000 in the United States and 101 per 10,000 in Canada (WHO, 2006).
A HOPE-FILLED ANSWER
Figure. FSIL Campus ...Image Tools
Faced with these facts, one might find it hard to imagine how the situation in Haiti could be reversed or where the people might find hope for their health and their future. But statistics are not the whole story. Numbers provide a measure of need, but they don't take into account God's concern for the poor and needy or the blessings he promises to those who care for them. Grim statistics do not limit the God of heaven who defends the weak, secures justice for the oppressed, offers refuge to the poor and needy, and provides for their daily needs (Leviticus 19:9–10; Psalm 82:3,140:12; Isaiah 25:4). Awareness of need can mobilize God's people to work toward effective and lasting solutions for vulnerable populations; and God promises to guide, satisfy, and strengthen all those who act on their behalf (Isaiah 58:10–11).
In Haiti, there is evidence of God at work through his people at the Faculty of Nursing Science of the Episcopal University of Haiti (Faculté des Sciences Infirmières de l'Université Episcopale d'Haïti [FSIL]) in the town of Léogâne, about 20 miles west of the nation's capital, Port-au-Prince. Amid lives of poverty and tremendous human struggle, Haiti's first baccalaureate nursing school is a bright spot of hope and promise to the Haitian people.
Thanks to the perseverance of a determined team of people, FSIL welcomed its first class of 4-year nursing students in January 2005. Since then the school has offered hope for Haiti's future by preparing professional, national nurses with the knowledge and skill to reverse the staggering statistics that have defined Haiti for too long. Although FSIL cannot solve Haiti's problems, it provides a remarkable model of how to build a country from within, by developing the capacity of its own people.
The idea for FSIL originated in 2001 as the dream of Dr. Jack Lafontant, then the Medical Director of Léogâne's 120-bed Hôpital Ste. Croix (HSC). Dr. Lafontant recognized the important role a school could play in reducing the country's nursing shortage and meeting critical healthcare needs. His dream was soon adopted by other Haitians from the Léogâne area and three nurse educators from the United States, Ruth Barnard, PhD, RN, Donna Martsolf, PhD, RN, and Jessie Colin, PhD, RN. These nurse educators spearheaded curriculum development, convinced that it was both necessary and possible to provide a baccalaureate nursing program within Haiti. FSIL's first dean, Hilda Alcindor, caught the vision and joined the team in 2004. Alcindor, a Haitian educated nurse who furthered her education in the United States and gained broad, invaluable nursing experience, shares she was specifically called and prepared by God to "give back to her people." Working together, these partners developed a new standard for nursing education that would improve the quality and scope of healthcare not only at HSC and in the Léogâne community, but throughout Haiti.
In 2004, the Medical Benevolence Foundation (MBF), associated with the Presbyterian Church (USA), obtained major funding for the initial classroom buildings and dormitory from the United States Agency for International Development, Office of American Schools and Hospitals Abroad (USAID/ASHA). Additional funds came from donors to MBF and the Presbyterian Church in the United States. In 2009, a second grant from USAID/ASHA made it possible to add a men's dormitory, a residence for the dean, and a security wall. The combined structures, all built to international standards, created a nursing school campus in the heart of Léogâne, Haiti, that projected a sense of hope and progress to the people of the area.
FSIL's baccalaureate curriculum is designed to prepare nurses according to national and international standards. The program is guided by FSIL's mission "to offer a professional program of study in nursing science, incorporating public health principles and practices, to prepare graduates for effective healthcare service as clinicians, leaders, and agents of change" (Haiti Nursing Foundation [HNF], 2008b, para. 1). The school follows the requirements set by Haiti's Department of Education and the Ministry of Health, two different departments within Haiti's government. These requirements assure that the content is culturally relevant and appropriate to meet the specific needs of the Haitian people. Both agencies have approved FSIL's program and credentialed their graduates.
The curriculum also meets expectations for the basic sciences, humanities, and social sciences described in The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008). FSIL's focus on the scientific method, the nursing process, research, the role of the nurse as an advocate, and the autonomy of the nurse are consistent with U.S. standards.
The quality of education at FSIL is a significant step toward bringing Haiti in line with global standards set by the WHO for the initial education of professional nurses and midwives. The WHO considers high-quality, university-level programs "imperative" because well-educated nurses can "strengthen health systems to meet population needs and protect the public" (WHO, 2009, p. 10).
The school's objective is to "provide its graduates with theoretical and clinical skills necessary for further professional education and growth, and an environment in which they can develop a desire for life-long learning and a passion for the ethical practice of nursing as a discipline of science, caring, and compassion" (HNF, 2008b, para. 2). Dean Alcindor sums up FSIL's purpose this way, "Our mission is to prepare responsible professional nurses, who are competent to prevent disease and promote good health in Haiti."
Not long after FSIL began to conduct clinical training within HSC, staff members reported a noticeable improvement in the level of bedside nursing care, patient and family education, and illness prevention. The students have had an impact in the Léogâne community by conducting workshops on urgent healthcare topics, such as AIDS/HIV prevention, and by participating in community health fairs. Although it will take time to measure the full impact of school's efforts, these improvements offer a glimpse of potential outcomes.
Because the FSIL program prepares Haitian nurses at a university level within their own country, students can apply skills and principles of professional nursing practice directly to the specific needs of the Haitian people. One issue often contributing to the shortage of nurses in developing nations is the migration of nurses to developed countries. Multiple factors cause such migration, including the fact that developed countries recruit foreign nurses to overcome their own nursing shortages. Nurses in a developing country, understandably, find it hard to resist the promise of greater opportunities in more developed lands (Aiken et al., 2004; Buchan & Aiken, 2008; Rosenkoetter & Nardi, 2007).
To combat this loss of nurses through migration, FSIL has set a goal to have 90% of its graduates still practicing in Haiti 5 years after graduation. The school inspires loyalty to country through regular repetition of the phrase, "We are the difference," as a reminder to students of the change they can bring to their people. Each class day begins with raising the Haitian flag and singing of the national song; and students are aware from the start that their academic diplomas will not be conferred until after they have given 2 years of service in Haiti.
Ultimately, FSIL's commitment to educate and retain nurses with baccalaureate degrees within the country will lead to an increased supply of nursing leaders who understand Haiti's cultural context for healthcare delivery. A nursing workforce that is fluent in the culture and language of the people provides the best opportunity for improving the health and well-being of a nation (WHO, 2006).
While it is a challenge for developed countries to keep up with the demand for nurses, it is even more so for developing nations. The success of FSIL, in spite of obstacles, demonstrates that it is possible to produce a nursing education program that meets global standards within a developing nation.
AN EXPRESSION OF CHRIST
FSIL, associated with the Episcopal University of Haiti, demonstrates a concern for the whole person that includes the spiritual dimension. The school's faculty members, dean, and board of directors recognize "the power of a Christian message" in all that they do, and they consider their program to be "an expression of nursing as a ministry of Jesus Christ where the spiritual dimension is an integral component along with teaching and healing" (HNF, 2008b, para. 1&2).
The school's core values help the students to integrate a Christian message into their nursing practice and lives of service. The first core value, "faith in Jesus Christ as our Lord and Savior and model for how to live our lives," precedes other values, which are focused on leadership qualities, excellence in all areas of life, respect, and advocacy (HNF, 2008a).
HAITI'S FIRST BSN GRADUATES
The 36 nursing students admitted to FSIL in January 2005 became the first class of baccalaureate nursing students enrolled in Haiti. This class also claimed a number of other firsts for Haitian nursing schools by including men, married students, and a few "older" students. (Students in their 20s are considered to be older in a country where the median age is 21.)
In developing countries it often takes time for students to grasp the high standards of study expected of university level education. Few high school graduates are prepared to handle an advanced level of education, compared to the numbers of students prepared for college level studies in nations such as the United States or Canada. As a result, some students in the first class ended up delaying graduation or dropping out. In addition, the realities of life in Haiti took a toll on the student body. For example, a hurricane in 2008 caused some students to delay or discontinue their studies.
Fortunately, a core group of students were able to press on and the first 13 students to complete the program graduated on January 10, 2009. The dream of many people had become a reality and the first baccalaureate nursing graduates were ready to make a difference in Haiti. A second group of 16 students graduated in December 2009. Some graduates remained to teach for the school while others assumed nursing positions throughout Haiti. But no one could have anticipated the enormous role FSIL would play in the health and survival of their country just one year after its first students graduated.
EARTHQUAKE—SERVE YOUR PEOPLE
Dean Alcindor was in the midst of teaching a class when the 7.0 magnitude earthquake hit Haiti on January 12, 2010. Within minutes, everything the school stood for and believed in—from knowledge and skill, to a life of Christian service—was put to a test few nurses, faculty, or schools throughout the world will ever face. Alcindor recalls,
At 5:20 pm, while the students were still hysterical, we got our first victim—a year and a half old baby. The students were on the ground, crying, and I knew I had to do something to move them to action, so I looked at them and told them, "Nobody asked you to come to nursing school; nobody forced you to be here. You are here because you want to be nurses. Your call is to serve your people. You need to get up and work. Here is your first patient." The baby wasn't breathing. So, they got up, gave CPR, and revived the baby. After that we had a flow of people and the students just kept on working.
Around them the town of Léogâne, which was near the epicenter of the earthquake, was in shambles; 90% of the buildings were destroyed and tens of thousands of people had been injured and/or buried by the rubble. Just 20 miles away, the capital of Port-au-Prince lay in ruins. The National School of Nursing there had collapsed, killing many of its nursing students. Hundreds of thousands of people were trapped, injured, or dead. The entire infrastructure of the country was disabled and roads were blocked. It would be days before any outside relief would reach Léogâne. But at FSIL, by God's grace, no one on the campus had been injured, and the buildings remained standing. As Dean Alcindor, faculty, and students faced the horrors around them, they responded as they had been instructed. Knowing the culture and the language, within minutes of the earthquake, their valuable training prepared them to make an immediate difference between life and death for many people.
Shocked and hurting people quickly turned to the nearest medical personnel who came to mind—the nursing school. Once a few people found help at the school, it didn't take long for word to spread throughout the community that help could be found at FSIL. First year students, who had just finished a class on splints and pressure dressings, put their new skills to work immediately. Upper class students did whatever was needed, from triage to assessment to suturing. Several students assisted with the life-saving amputation of a little girl's arm. A moment of joy arrived the day after the earthquake hit when a baby was delivered on the porch of the Dean's house. A graduate from the school's first class helped with the delivery and continued to assist with the birth of many other babies. Most of these children proudly bear the name of the nursing student who helped in their delivery.
Eventually a bit of aid arrived from international organizations such as Doctors Without Borders, and a Japanese team that set up a field hospital on the school grounds. Students assisted these medical teams, dorm rooms were transformed into surgical suites, and more FSIL graduates arrived to assist as the campus became a haven of much needed help. Meanwhile, the yard around the school became a tent city for hundreds who had nowhere else to go.
Dean Alcindor shepherded her students through this unprecedented experience with direction, instruction, and consolation. Classes were canceled, but a lot of exceptional learning took place—learning about life as well as nursing. After the initial crisis had passed, some students joked they deserved to receive extra credit for their work.
Alcindor recognized that the students' response to the needs of their people had forever changed who they were and how they would live from that point forward. Dean Alcindor noted, "I kept telling them, 'You need to serve your people.' The earthquake shaped their lives. They learned how to be better citizens." As one student noted, "God blessed our hands. He helped us to serve others and save lives after the earthquake." A slide show about FSIL with before and after earthquake pictures is available online at http://links.lww.com/NCF-JCN/A7.
Undaunted by the earthquake, FSIL has pressed on. As soon as the Haitian Ministry of Education announced that schools in the Port-au-Prince and Léogâne area could resume classes, FSIL's Governing Board resolved to reopen the school based on the following points: (1) address physical and mental health needs, (2) restore the physical plant, (3) provide adequate supplies and equipment for clinical and education needs, (4) ensure the safety of the campus, (5) examine and update the curriculum, (6) recruit, screen, and schedule volunteer faculty, and (7) rebuild the business and financial systems supporting FSIL.
As the country of Haiti moved into the long recovery phase following the earthquake, classes at FSIL resumed. The original architect for the project, James Hite, returned to Haiti to assess the structural soundness of the buildings and clear them for occupancy. The classrooms, lab, and dorms were fine, although computers, books, and other supplies had been damaged. Thankfully, through donations, key supplies are slowly being replaced.
Like many people in Haiti, the students had to deal with "concrete phobia," a reluctance to enter buildings for fear concrete might fall on them during the many aftershocks that rocked the country. Therefore, classes were initially held in tents, until gradually the students were able to return to the classrooms.
As the dean and faculty members began to look at the long-term impact of the earthquake on their students as well as the Haitian people, they made plans to address related needs through curriculum revisions. For example, they brought in a team of mental health professionals from Mt. Sinai Hospital in New York City, to help students learn how to deal with the trauma of the disaster in their own lives, along with teaching them strategies for helping the Haitian people to recover mentally as well as physically. The curriculum was revised to include updated information on grief and loss, rehabilitation, and posttraumatic stress disorder.
Nine months after the earthquake, a cholera outbreak invaded Haiti and quickly spread in this ravished country. By the end of 2010, thousands had died and predictions were that thousands more will die as a half million people become infected in 2011 (Pan American Health Organization [PAHO], 2010). As FSIL had done when the earthquake hit, the nursing school responded quickly to the cholera outbreak. Students went to various local schools and churches in Léogâne to educate people on the modes of transmission, prevention, and treatment of cholera; and several students spread the word via radio. One local businessman was so impressed by the teaching the students did at his church that he called Dean Alcindor and requested they do the same presentation for his employees. Along with the WHO, International Red Cross, and other relief agencies, FSIL has become part of an important health teaching and intervention to help prevent and treat cholera in Haiti.
In spite of the disruption of a major earthquake, cholera epidemic, and overall challenges of daily life in Haiti, 23 students were able to complete the program and meet the requirements for graduation in December 2010. At the same time, 40 freshmen were slated to begin their educational journey.
At present, FSIL depends on volunteer educators from the United States to supplement local faculty, especially during this time of recovery and rebuilding. In order to coordinate arrangements, a system was arranged for screening potential volunteer educators and matching their areas of expertise with the school's teaching needs. A committee reviews resumes to determine that each volunteer who is accepted has the educational credentials and experience to teach in their baccalaureate program. Upper level students are fluent enough in English to be taught in English. Graduates of the program, Dean Alcindor, and upper level students are available to provide translation when needed for lower level students.
Because there are currently no master's degree nursing programs in Haiti, FSIL is eager to offer advanced degrees in nursing education in the future. The ability to prepare nurse educators within Haiti would be a momentous step forward in transforming the future of healthcare in the country (WHO, 2006, 2009). Meanwhile, the board has been exploring opportunities for graduates to obtain a master's degree while remaining in Haiti, through online options with established programs.
In August 2010, the HNF, the support arm of FSIL, hosted an international symposium on the theme of "The future of nursing education in Haiti." The symposium brought together directors of schools of nursing in Haiti and nursing organizations in the United States working in Haiti. As a result, HNF is working with Haitian educators to implement a 5-year plan to advance nursing in Haiti; and the foundation has joined forces with the WHO/PAHO Collaborating Centers at Columbia University (New York) and the University of Michigan, as well as American nursing organizations and schools of nursing to coordinate efforts in the major areas of need identified by the symposium's 12 nursing educators and the Haitian Ministry of Health.
The school aims to conduct research in the international health field, and to develop affiliations with international nursing organizations, such as the International Council of Nurses and Sigma Theta Tau International (HNF, 2008b). If the perseverance demonstrated during the earthquake disaster is any indication, FSIL is quite likely to reach these goals and beyond!
The remarkable response of FSIL's nursing students and faculty during the earthquake saved lives, gave hope to a community in need, and demonstrated the positive impact of well-educated nurses on the health of a nation. FSIL's ongoing resolve to prepare competent professional nurses, who have the capacity to care for the specific and urgent needs of the Haitian people, holds the promise to transform lives and communities throughout Haiti. The health and human statistics may seem daunting, but not to those who are determined, with God's help, to prepare nurses who will become agents of change within their own country.
* Medical Benevolence Foundation—http://www.mbfoundation.org/
* Facebook—search Haiti Nursing Foundation
* "The Future of Nursing Education in Haiti" symposium—http://haitinursing.org/index.php/events/international-symposium/