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Original Research

Exploring Working Relationships Between National and Expatriate RNs on Humanitarian Aid Missions

The Perspectives of Liberian Nurses

Wilson, Deborah, MPH, MSN, RN; Jallah, Darlington S., MPH, RN

AJN The American Journal of Nursing: June 2019 - Volume 119 - Issue 6 - p 49–60
doi: 10.1097/01.NAJ.0000559806.91187.47
Original Research

Purpose: This qualitative study was conducted to explore the perceptions and concerns of Liberian RNs who work for international nongovernmental organizations (NGOs) in Liberia, and to elicit insights and suggestions about how to improve collaboration between national and expatriate nursing staff.

Methods: Five focus groups involving 19 nurses and an individual interview with one nurse were conducted. A semistructured interview guide was used to gather perspectives and garner suggestions. A phenomenological approach was used to identify emergent themes.

Results: Regarding positive experiences, participants from all 10 NGOs reported that working with expats gave them opportunities to be mentored, learn new skills, and try out new techniques and equipment. Negative experiences included problems with disrespect and expats’ lack of cultural competency. Participants spoke of adverse patient outcomes that resulted when expats made assumptions and wouldn't listen to national staff.

Conclusions: The findings indicate that changes are warranted in the current work culture between national and expatriate nursing staff. Improving collaboration between national and expatriate RNs could lead to higher-quality care and better patient outcomes. Predeployment training for expatriates that incorporates the voices of national staff is recommended; this would raise awareness of the realities of nursing in low-resource settings and promote respect for national staff.

The authors of this qualitative study explored the perceptions and concerns of Liberian RNs who work for international nongovernmental organizations in Liberia, yielding insights on how to improve collaboration between national and expatriate nursing staff.

Deborah Wilson is a doctoral candidate at the Johns Hopkins University School of Nursing in Baltimore, MD. As an RN, she has been working in international nursing for the last 30 years, with specialties in emergency medicine, neuroscience, and trauma. Her article “Inside an Ebola Treatment Unit: A Nurse's Report” appeared in this journal in December 2015. Darlington S. Jallah is a county nutrition officer at Action Against Hunger, a global nonprofit organization, assigned to Margibi County, Liberia. He is working toward his second master's degree, studying at Cuttington University's School of Graduate and Professional Studies in Monrovia and lecturing at both CEPRES International University and CENSIL College in Montserrado, Liberia. At the time of this study, he was a researcher at Action Against Hunger. The authors acknowledge Nancy Glass, PhD, MPH, RN, FAAN, professor of nursing at the Johns Hopkins University School of Nursing and associate director of the Johns Hopkins Center for Global Health, for her guidance in creating the questionnaire and study protocol design. This research was supported by discretionary funds from the Johns Hopkins School of Nursing research faculty and the dean's travel and conference fund. Contact authors: Deborah Wilson,; Darlington S. Jallah, The authors have disclosed no potential conflicts of interest, financial or otherwise.

At this moment, humanity faces an unprecedented number of large-scale crises in countries worldwide, including Afghanistan, the Democratic Republic of Congo, Iraq, Somalia, Syria, and Yemen, among others.1 An estimated 65 million people have been forcibly displaced; another 100 million nondisplaced people are struggling for daily survival.2 The needs these crises generate and the complexities of providing care to the affected populations continue to increase. In June 2017, the Lancet published a four-article series called “Health in Humanitarian Crises” that outlined several of the contributing issues.1 These range from underfunding by donors and the protracted nature of national emergencies (whether they're caused by armed conflicts or natural disasters) to variations in the quantity and quality of the evidence base for health care interventions—and the failings and harms of such interventions.3, 4 Series authors identified improved data collection, greater resources, and funneling money to national and indigenous agencies rather than international organizations as vital to improving public health during large-scale crises.3, 4 The difficulties of such situations can seem overwhelming. As Spiegel has stated, the existing humanitarian aid system wasn't designed for the complexities of modern crises; it no longer fits its purpose, and must be changed.2 He also acknowledged that although it's widely accepted that “affected persons and communities must be at the core” of humanitarian decision making, this rarely happens.

L'Anson and Pfeifer have argued that nongovernmental organizations (NGOs) ignore the agency of the individuals and countries they come to aid—and, in so doing, can actually cause harm to the very people they've come to help.5 Cunningham and Sesay described this further, stating that the increasing involvement of NGOs in crisis situations carries increased risks: “Harm can be caused not only to patients; culturally inappropriate care can also damage working relationships at an organizational level.”6

Indeed, for both national and expatriate staff on humanitarian aid missions, tension in their working relationships is among the most common reported stressors.7, 8 (In this article, the term expatriate refers to anyone from outside the home country who is living and working onsite temporarily.) Suggestions for improving these relationships have included developing tools for ethics training for expatriate staff8; raising their awareness regarding the limitations of their understanding of the host country8; and teaching them to practice with respect, humility, and an attitude of collegiality.6, 8 While these suggestions are good ones, they have been developed through the lens of the expatriate. There has been scant research investigating the experiences and perspectives of national staff, particularly with regard to working relationships with expatriates. We wanted to address this knowledge gap.

Study purpose. This qualitative study was conducted to explore the perceptions and concerns of Liberian RNs who work for international NGOs in Liberia, and to elicit insights and suggestions about how to improve collaboration between national and expatriate nursing staff.

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A recent systematic review by Strohmeier and Scholte found that, although the “vast majority” of humanitarian aid workers (up to 92%) in a given crisis are national staff, most studies investigating trauma-related mental health issues have focused on expatriate staff.9 And many NGOs lack the resources to provide adequate support for their staff. As Cardozo and colleagues have noted, services and benefits such as basic health care, psychological support, salaries, and security policies are typically less comprehensive for national staff compared with expatriate staff.7 They also pointed out that national staff may belong to the populations and communities affected by the crisis and thus may already be suffering from stress and trauma. The majority of qualitative studies investigating their experiences have focused on posttraumatic stress disorder and other mental health issues, not on their working relationships with expatriates.

In discussing the risks posed by the involvement of international NGOs in humanitarian aid missions, Cunningham and Sesay identified a “triple menace”—three potentially harmful elements of short-term actions that are all rooted in a lack of cultural humility on the part of the expatriate workers: emergency mind trap, volunteer entitlement, and leadership misinterpretation.6 Emergency mind trap refers to a mindset in which humanitarian aid workers attempt to implement quick fixes in situations that are actually part of a protracted crisis. Volunteer entitlement refers to how compassion fatigue can lead to apathy and to an attitude among volunteers that since they aren't being paid, they can do whatever they want. Leadership misinterpretation refers to expatriates’ failure to recognize and acknowledge the national leaders and agencies that are already in place.

Hunt and colleagues have considered the ethical challenges faced by expatriate health workers during short-term medical missions.8 Commenting on the importance of “engaged presence,” they noted that expatriate staff tend not to communicate and coordinate efforts with national staff; this can increase stress and cause unintended harm, as when expatriates “transgress local customs and values through a lack of awareness.”8 Improving collaboration is one way to diminish power imbalances, prevent the replication of colonial patterns, and lead to more efficient and effective programs.

The World Health Organization (WHO) has defined collaborative practice as occurring when “multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care.”10 The WHO further acknowledges that collaborative practice can strengthen health systems and thus improve health outcomes.11 It's clear that understanding the complex perspectives of all parties is vital to creating truly collaborative practice.



For additional background, see Keys to Understanding Liberian Culture.12

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This study took place in Monrovia, Liberia, during November 2017. Monrovia, the capital of Liberia, is home to more than 70 international NGOs.13 Approval was obtained from institutional review boards (IRBs) at the Johns Hopkins University and the University of Liberia's Pacific Institute for Research and Evaluation before data collection began. The study was an independent research project conducted by both of us: DW is a New Zealand nurse, currently based in the United States, who has worked as an expatriate nurse on humanitarian aid missions in Chad, Haiti, and Liberia, and DSJ is a Liberian nurse who has worked with international NGOs on various projects focusing on issues such as malnutrition, maternal–child health, and Ebola. We first worked together in a 120-bed Ebola treatment unit in Foya, Lofa County, Liberia, during the 2014 West African Ebola outbreak. Since then, we have continued conversing about how to improve working relationships between national and expatriate staff.

Sample. The criteria for participant selection included being a Liberian RN, having worked or currently working for an international NGO, and having worked or currently working with expatriate RNs. Ten international NGOs based in Monrovia were contacted. The Liberian researcher spoke with an RN who fit the above criteria at each organization. These nurses then reached out to colleagues who also fit the criteria, for a total of 30 eligible participants. This method of selection, called snowball sampling, was chosen because it's a strategy known to support theory-building and inductive processes.14 The eligible participants were notified of when the focus groups would be held. Both morning and afternoon sessions were made available.

Study design. This qualitative study used a phenomenological approach for two reasons: first, phenomenology considers participant data thematically in order to extract meaning,14 which suited the study purpose; and second, both of us are nurses with an investment in improving national–expatriate RN working relationships. A phenomenological approach involves applying the researchers’ personal comprehension, knowledge, and sensitivity to their topic.15



Instrument. The researchers developed a semi-structured interview guide, which was then reviewed by two nursing and global health professors, one from the Johns Hopkins School of Nursing in Baltimore, MD, and one from Villanova University's M. Louise Fitzpatrick College of Nursing in Villanova, PA. The guide was also reviewed by a Liberian nurse who works with Jhpiego (, a Johns Hopkins University–affiliated international nonprofit organization that works with health experts, community leaders, and governments to strengthen health systems in developing countries, and by the Liberian country lead at the Carter Center Mental Health Program (, where she coordinates interactions between national and international colleagues and partners of the program. Their feedback and suggestions were incorporated to ensure cultural relevance and appropriateness. Feedback from the Liberian IRB was also incorporated. The interview guide was in English, which is the national language in Liberia. After the first focus group, the interview guide was revised slightly, rephrasing some questions from formal to “Liberian” English, and clarifying others. Based on unprompted recommendations given by the first group, we also added a question to elicit recommendations. See Interview Guide for the final version.

The guide consisted of 12 open-ended questions that covered several topics, including the nature of national–expatriate RN working relationships, conflicts and conflict resolution, decision-making processes, the impact of national–expatriate RN relationships on patient care, ethical considerations, and recommendations for improving these working relationships. Further probing questions were added to enable extended discussion on issues that arose during the interviews. These probing questions evolved over time. In an effort to minimize the inherent researcher–participant power imbalance, and since both of us are nurses, we used a participatory action research model,14 including ourselves in the discussion and providing examples from our own experiences.

Procedure. Each of the five focus groups began with introductions and proffered beverages in order to create a relaxed atmosphere. The Liberian researcher facilitated the introductions and then handed out a written description of the study purpose and the risks and benefits of participating. Participants were given time to read the description and ask any questions. Confidentiality was addressed: participants were asked to respect the need for confidentiality and to avoid discussing what was shared outside the focus group. The researchers also explained that the names of participants and the NGOs they worked for would be deidentified. To ensure that participants felt they could speak freely, we also explained that if at any time participants felt uncomfortable with either of the researchers, that researcher would gladly leave the room. Verbal consent to be interviewed and recorded was then obtained, after which audio recording began.

Both researchers were present at each focus group and at the individual interview. The Liberian researcher asked the questions and the U.S.-based researcher took notes. Although the interviews were conducted in English, at times the U.S.-based researcher and the participants had difficulty understanding one another; when this happened, the Liberian researcher would “translate.” All interviews were transcribed on the day they took place by the U.S.-based researcher, and were checked for accuracy by the Liberian researcher. Any questions about the meaning of comments, phrases, or issues raised were discussed between the two researchers. The recordings were destroyed once transcription was complete. All participants were reimbursed ($25 USD each) for time taken off work and travel expenses.

Although the 2014 Ebola outbreak was not the focus of our inquiry, we knew it was likely to come up, since every Liberian nurse had been involved. During that crisis, according to the WHO, 372 Liberian health workers contracted Ebola, and 180 of them died.12 Moreover, the outbreak had severely taxed Liberia's health care system. The Liberian IRB requested that we consider the stressful nature of that crisis when interviewing participants. Thus we took extra measures to ensure that participants felt safe. This included conducting the interviews away from work sites in a neutral, pleasant environment; affirming that all data were deidentified; offering free mental health counseling if the need arose (the Carter Center provided a list of available counselors); and assuring participants that anyone could take a break or stop the interview at any time and still receive financial compensation.

Data analysis. The semistructured interview guide provided a basic framework for each session, while also permitting the development of more free-flowing conversation. Because the same root questions were asked in the same order, results could be compared across interviews. Once each transcript had been double-checked for accuracy, we analyzed the data line by line, looking for commonalities, similarities, and differences and identifying and hand-coding themes as they emerged. (No software was used.) Next, each of us separately coded these themes into common conceptual categories; then we met to discuss these categories until consensus was reached. Similar concepts were grouped together; for example, the category “lack of respect” included comments such as “harsh,” “fast to complain,” and “don't appreciate the language barrier for us.”

As a further effort to minimize the researcher–participant power imbalance, after the first round of data analysis, a letter was sent to each participant thanking them for participating, outlining the findings, and inviting their feedback and thoughts or concerns about how the data would be used.

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Sample. Of the 30 eligible participants, 20 appeared at the scheduled times to be interviewed; thus the final self-selected sample was 20 nurses. Nineteen nurses chose to be interviewed in focus groups and one nurse chose to be interviewed individually. All interviews were conducted within one week. Of the 20 participants, 10 were male and 10 were female; this 50–50 split was random. Participants’ ages ranged from 27 to 42 years. At the time of the study, 11 participants were working for Liberia's Ministry of Health at various government clinics around Liberia (Monrovia, Bong County, Margibi County, and Grand Cape Mount County), four were working for different international NGOs, two were working in a hospital on a medical–surgical floor, and three were unemployed.

No demographic data for the expatriate staff could be collected as the Liberian nurses were describing experiences from multiple past interactions in different contexts, including projects addressing malnutrition, HIV, malaria, pediatric and maternal–child health, and Ebola. Expatriate nationalities that were mentioned during interviews were American, Danish, Swiss, and Kenyan. Reported lengths of expatriate nurses’ time working in Liberia ranged from four weeks to one year.

Findings. The first, two-part question asked participants to speak to the positive and negative experiences of working with expatriate nurses. Regarding positive experiences, participants from all 10 NGOs reported that working with expats gave them opportunities to be mentored, learn new skills, and try out techniques and equipment that they hadn't worked with before.

“It exposed me… to sophisticated machines, things like SpO2 [peripheral oxygen saturation] and deep breathing masks…. I see [this] extra equipment, so I know that these things exist—at least in the Western world.”

Descriptions of work plans and systems improvements that helped their organizations become more effective and efficient were peppered throughout the discussions.

“Expat[s] have made some important impact on the Liberian health system, such as when they come to operat[e] a health institution or system…. I left from Hospital [name omitted] two years ago. I just took a walk there yesterday to see how the hospital was running. You see improvement… they help to improve the system gradually through teaching, equipment, machines that we can work with.”

It also became evident that working with expats influenced participants’ relationships with themselves as nurses and with their profession.

“The expat, you will see them playing with a sick child. Most of the national staff, we don't see it from that perspective. We just say “come here” to the child. I want to be that nurse that brings light to my patient[s] and see how my patient[s] are doing because of my intervention and that to see that they are happy to see my coming.”

“The expat respects the patient view…. It gave me the courage to live up to the ethical practice that I have been taught.”

Regarding negative experiences, among the most common complaints were that expats were always “the boss” and that some demonstrated a lack of respect.

“Some [expats] want to learn, but others, they feel that they are the boss. So they always want you to take command from them. You have to do what they say. They don't want to listen to your opinion. What they tell you to do is [what] you have to do.”

“I have seen [an] expat try to do everything for the patient to save a patient and the patient still dies and nobody criticizes [the expat]. They give oxygen et cetera and the patient died, and they don't have to do an incident report… like we do.”

“When working with an expat supervisor you are not always free. It's like you have a satellite watching every move you make, and it makes you nervous.”

“I don't have problem with [the expat being the boss]; what I do have problem with is the respect. If I don't get the respect I deserve from you, of course obviously I have a problem.”

Several comments were to the effect that Liberia's Ministry of Health was the problem, not the expats.

In three of the focus groups, the issue of racism arose and was discussed. One participant said,

“The white always uses the black as an example. It's like the Americans come to practice on us. They make more money and get good housing, but they push the work on you.”

It was acknowledged that Liberian nurses work with both white and black expats, and in this group the consensus was that how they were treated was what was important, not the expat's skin color or supervisory role.

The next question was “What expectations did you have of working with the expat?” The most common response was an expectation that the expatriate RNs would have greater knowledge or experience (or both) compared with the national nurses.

“I expect the expat—as we are both nurses—where she got her training from, she got more experience, so I expect to gain a little extra knowledge from her…. I feel we both learn from each other.”

But other participants reported finding that expats didn't always live up to their high expectations:

“[When we're told] this person is an expat, we think they know all…. We give them the time and respect and whatever they say because they come and act that they know. Sometimes they tell you to go do it and actually it is not right and they make you feel that they know more. You are afraid to tell them it is not right way.”

And sometimes, as one participant reported, the expats dispensed their knowledge “on social media and iPhone, [but] leave national staff to do all the work.”

We also asked how patient care decisions were made and whether national staff were included. Many participants expressed frustration about being excluded from decision making, meetings, and even rounds.

“Decision making about patient was done among the expat team. They discuss among themselves and come and say this is what we will be doing today…. They don't ask for your input whether it is right or wrong…. Nursing work, it is a team work. You get my input. Listen to me and let me tell my view. [But] we are not part of the decision making. We were not part at all.”

Another common complaint was that expats adhered rigidly to their particular NGO's protocol book (which participants often referred to as the “Bible”). The Liberian nurses were frustrated with not being able to give input based on their usual practices and protocols.

These first questions led the first focus group to offer suggestions for improving national–expatriate RN working relationships, and we added a question specifically asking for recommendations in subsequent interviews. In all focus groups and in the individual interview, participants voiced their desire to be invited to meetings; included in planning, strategizing, and decision making; and have their input valued. The most common recommendation was for expats to collaborate.

“When the expat is coming in—it should register on the expat mind that nursing is the same all over the world…. So when the expat comes they should cooperate with the national staff, discuss together whatsoever activities that they are going to carry on, be it training, be it mentoring, but not think they are just the boss.”

“As we are both nurses… I expect to gain a little extra knowledge from [the expat] and she [to] gain a little from me. To be honest, some expats come and want to learn from us and as much as we learn from them—so then I feel we both learn from each other.”

The next question asked “What ethical issues did you deal with?” and sought examples. Issues concerning confidentiality were discussed, as well as the ramifications of certain cultural differences. For example, several participants reported feeling uneasy when expats came to work with visible tattoos and facial piercings, which are unacceptable in Liberia. Of note was the frequency with which participants mentioned hiding information from expatriate nurses, out of fear that the expats would overreact or disrespect their way of doing things. One participant said,

“In the case of rape, the family says let's compromise, let's talk about it as a family matter… instead of reporting it to the police. But the expat says, “No, you have to report it.”… For us, with some families we don't want to take the case to the law so we just keep the record. If an expat is involved, they want to dig up a lot of things and report…. Most national staff will not report accurate information to the expats, they will keep some information secret, for fear that the expat will escalate the situation and upset the family.”

Several participants also said that sometimes they documented administering a drug that had been ordered when in fact they had not, fearing it would harm the patient. Their rationale was that if the patient died, they would be blamed. They were aware that such decisions put them, as one said, “between the two blades of a pair of scissors.” They were not comfortable questioning a physician's order, usually because they feared either public reprimand or loss of employment.

Both when answering the question “Did you ever have concerns about the care of a patient (or patients)?” and at other points during the interviews, nurses spoke of adverse patient outcomes that resulted when expat nurses made assumptions and wouldn't listen to the national staff. One participant offered this striking example:

“I notice about expat[s], when they come, they already come with their mindset they know it all. “Hey do this, do this.” At one place… I don't want to say that it was the cause of the increase in malnourishment… but to some extent it contributed…. Most expats saw poor skin turgor and sunken eye and say, “They are dehydrated” and order fluid. I talk to them and say, “Hey look at the national protocol—fluid is not the answer.” There was a whole lot of fluid ordered by the expats. But they came with the mind[set] that they know [what's best]…. It was not really cordial between expat[s] and national staff because the expat[s] thought they were in control of the knowledge. I saw it 10 times, 20 times—it got to the point that I had to call a clinical conference to give them the reason on why these children are different—explain to them how to do correct fluid management—to clarify.”

“[Interviewer] Did they listen?”

“[Participant] Yeah… they stopped [giving the fluid] and then the children improved and that was a clear indication.”

Regarding conflict, participants were asked, “If you had a conflict with an expat, how did you resolve it?” The most frequent response was that the Liberian nurse discussed the conflict directly with the expatriate nurse.

“Don't confront someone aggressively. Have a peaceful mind. If you hurt, don't pretend; tell the person you are hurt about what have happen. Once someone tell you they are sorry, it is off their mind. So you take into consideration what they have said, then let it go.”

Some indicated that they involved a supervisor:

“Get the supervisor for national staff informed about the situation and then supervisor probably has the ear of the expat as well. You don't just go and confront that person—you won't be resolving the issue. You deal with the supervisor first.”

Only a few responses involved apologizing for or ignoring the conflict.

“I am weak—meaning if humans have a misunderstanding at that moment, I won't be able to say anything for a day or two. I need time.”

“Really you can't do anything. I am not shy and will say my side of the story, but most times they just justify their position and don't listen. Sometimes they apologize.”

Another question concerned the fact that expatriate RNs are always given a supervisory or “boss” role. Asked how they felt about this, participants most often indicated that this was acceptable to them, especially if the working relationship was collaborative.

“I feel fine. Because looking at our country, we are living in third-world country. They have higher knowledge and they have some ideas that they can help us with our country.”

“Someone has to be the leader… if we do not advance, then we stay static.”

“What you are learning from them, you are learning it for yourself. When they are gone you can also implement what you have learned from them.”

Only a few responses suggested mixed feelings. One participant said,

“But I get demotivated when you have same qualification and get the supervisor role, but you don't know how to do the work. Then I have a problem with it. You need to prove yourself to me.”

To the question “How has your nursing practice changed since working with the expat?” participants reported improved collaboration and patient care, improved professionalism, and developing new skills. Learning to respect time was also frequently mentioned, both in direct response to this question and at other times during discussions.

“Since I worked with an expat in the emergency room, I tried practicing how she is interacting with the patients. And now my patients say, “You were smiling,” and they really like how I am, and I am proud of that.”

“Liberians, we don't respect time. But they [expats] respect time and deadlines, so we learned to… be prompt in timing. If I [am supposed to] come to work at 8, I come at 8, not 9.”

Although the 2014 Ebola outbreak wasn't the focus of our research, all of the participants had been affected by it, and we expected it to come up during interviews. So we also asked, “How has your nursing practice changed since the Ebola outbreak?” Some references to national–expatriate RN working relationships were made. One participant said,

“They [the expats] also help us… learn other things—washing with soap and water and always using gloves, universal precautions. That was not done [prior to the outbreak] and we were caught by Ebola. With trainings and new ideas, we are improving our health system. We also learned isolation techniques.”

Some comments were indirectly relevant to our focus on working relationships, in that national nurses spoke of how the outbreak increased their sense of agency and collegiality among themselves.

“There [are] now surveillance officers—county and district, just in case of any disease, we will combat it and if we can't cope [in the county] the district will come. We now have a big weapon. There is a ledger that you can trace for any disease and follow cases. In Bong County there is a machine to test for Ebola, and other counties have a strategy to travel to Bong if they need to get [patients’] blood tested.”

“The Ebola outbreak has brought us nurses together. We are watching out for everything. There is a unity and friendship [among] nurses. Our consciousness has been increased as we have to save ourselves…. Yes, togetherness in nursing.”

We then asked, “What special skills do you as Liberians bring to nursing practice?” in order to give national nurses the opportunity to reflect on their value and achievements. Participants spoke of their improved ability to provide safer, high-quality care and of the value of their knowledge and respect for Liberian culture and norms.

“We have to keep reminding them of our situation here. We don't have this equipment, so we don't do this procedure. We help them work in line with us here in Liberia.”

“Now we are trained in SQS [safe and quality health services]—we are trained in how to care for patients after the Ebola crisis in the right way.”



“We provide key information on the health status of our people. What areas are lacking behind, like maternal–child health. We also provide information as to how the intervention [that was] implemented and funded actually worked or not.”

See Participants’ Responses to Selected Questions for a list of answers to selected questions.

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There is strong evidence that collaboration among health care providers improves care quality and patient outcomes and contributes to the personal growth of the collaborators.16 Moreover, according to the WHO, teams that work collaboratively are more successful in difficult and austere settings than teams that do not.10, 11 This study was conducted in order to explore Liberian RNs’ experiences in working with expatriate RNs during humanitarian aid missions, provide opportunities for them to discuss positive and negative aspects, and elicit recommendations for improving collaboration.

Themes. When we reviewed our findings, several themes emerged. Among them were collaboration, coping with conflict, desire for more education, knowledge gains, motivation, respect or lack of respect, salary, and “the boss.”

First, there was a clear desire on the part of the national nurses to be treated as any of us would want to be treated. Overall, the Liberian nurses described more positive than negative experiences in working with expatriate nurses. The fact that expats were always assigned supervisory roles was not an issue if the expats didn't abuse their position and worked collaboratively with the national staff.

But participants reported having issues when an expat was disrespectful, or when national and expatriate RNs were held to different standards. Some participants said that if they spoke up about an expat's poor behavior, the expat might soon be gone without explanation. Moreover, if an expat was disciplined, it was done in private and the national staff were not informed. If a Liberian nurse was disciplined, it was usually done publicly in front of patients and families, which was embarrassing and humiliating.

Although not specific to national–expatriate RN working relationships, participants also spoke of their need for more equitable wages and further training. According to participants, a Liberian nurse typically earns $250 USD a month, whereas a physician typically earns $2,500 USD a month. (The Frontline Health Workers Coalition has reported that average Liberian salaries are $250 USD a month for nurses and $500 USD a month for physicians; although that estimate for physicians is lower, it's still twice what nurses make.17) And although expat nurses’ wages weren't brought into the discussion, in the U.S.-based researcher's experience NGOs pay volunteer wages that are higher than what national nurses earn. During one focus group, a participant asked the U.S.-based researcher if she could live on $250 a month, to which the researcher replied, “No.” Some nurses explained that their poor wages undercut their motivation to come to work on time. Several nurses also expressed a yearning for more education.

“It's not just about increasing salary, but nurses need to step up to the plate. To give the real strength. Even our doctors and others look at nurses as nothing. We need to get more training after nursing school.”

“The national Liberian nursing board—my suggestion for them is that they need to come up with continuing education programs for nurses. Nurses play so many roles—manager, counselor, bedside [nurse], research[er]. So we should have continuing education, so that we can be empowered and able to give holistic care.”

Other themes that emerged included ethical concerns, exclusion, language barriers, Liberian nurses’ skills, new equipment, patient deaths associated with lack of collaboration, racism, and the Ministry of Health. The desire for respect, professionalism, and recognition for participants’ hard work pervaded all of the discussions.

Implications. The findings of this study indicate that changes are warranted in the current work culture between national and expatriate nursing staff. Most of the Liberian nurses spoke of collaborating effectively with some expatriate nurses. But there is clearly a need for more respectful, mutually beneficial working relationships.

According to Leape and colleagues, fostering a culture of respect is critical to creating a “safe, high reliability organization.”18 Disrespectful behavior, whether overt or subtle, threatens the well-being of patients and staff. They also state that mutual respect and collaboration are essential to effective teamwork and the implementation of best practices. The responsibility for creating a respectful, collaborative work environment falls mainly on the shoulders of organizational leaders. Thus, NGOs need to make sure that such a mandate is made explicit to its leaders, written into its policies, and incorporated in its humanitarian aid missions.

To this end, the voices and stories of national nurses could be incorporated into predeployment trainings for expatriate nurses. This would raise awareness of the realities of nursing in low-resource settings, and would convey national nurses’ right to be treated as equals and to have their opinions and experiences valued. In the field, the responsibility for respecting the perspective of national staff falls on the shoulders of expatriate staff. Doing so ensures a greater professionalism in humanitarian aid.

The anecdotal evidence reported by this study's participants indicates that improved collaboration would result in improved clinical outcomes. More formal, mixed-method studies that document and quantify the effects of improved national–expatriate RN working relationships on patient outcomes during humanitarian crises are needed.

Limitations. Although there were similarities in the comments from nurses who worked for 10 different NGOs, nurses working in other NGOs or other countries might not face the same issues. Thus, these results can't be generalized. The study sample was both small and self-selected; a larger, more randomly chosen sample would allow more confidence in the independence of the expressed viewpoints. Moreover, four of the participants had worked with us previously in Foya during the 2014 Ebola outbreak. This may have influenced their responses. During the interview process, we realized that we tended to focus on finding the negative aspects of the national–expatriate RN working relationships. The U.S.-based researcher's prior experience on humanitarian aid missions may also have influenced our focus. We made every effort to be more objective in how we presented information, but our bias may still have affected results.

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This study gave Liberian nurses an opportunity to discuss in confidence their experiences in working with expatriate nurses during humanitarian aid missions. It allowed their voices to be heard, and yielded valuable insights into what works and what doesn't in national–expatriate RN working relationships. We hope that their comments, concerns, and recommendations will be used in training sessions for expatriate nurses in order to enhance expats’ understanding and ability to work collaboratively in cross-cultural settings. We also hope that our findings will help lead to the increased efficacy of international humanitarian aid efforts and to better clinical care of patients during crises.

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collaboration; cultural competency; cultural differences; Ebola; expatriate nursing; humanitarian aid workers; Liberia

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