FROM THE BEGINNING of the Christian era to the present, nurses have demonstrated the inward conviction of their calling by outwardly going to the ends of the earth to care for the sick. The “going out” to render needed care to the poor is seen as fulfilling the very words of Christ, and nurses continue to serve in international healthcare relief and development with that motivation (O'Brien, 2003; Shelly & Miller, 2006).
As the context of missions has changed in this new millennium, what of missional nursing?
Missionary nursing is changing from historical to newer methods, driven by the shifting realities in the developing world (Fountain, 2004). One influencing factor is the emphasis away from long-term foreign mission service to short-term medical outreach trips (Hershberger, 2004).
Hospitals were the historic medical mission concept. Beginning in the early 1800s, Euro-American religious organizations sent physicians and nurses to establish hospitals in remote locations, to deliver healthcare in promotion of the Christian faith, and to care for missionaries sent to these regions (Van Reken, 1987). For nurses, this was congruent with the missional view of the nursing movements in the West (Shelly & Miller, 2006). Missionary nurses served in long-term or life-long commitments because “it took several months to physically get to the field, and people often got sick or died in a matter of a few years or even months, and if they survived they labored long years without ever returning to their country of origin” (McKaughan, 1997, p. 16). Language acquisition, cross-cultural understanding, and close relationships with nationals were part of this service (Tazelaar, 2001). History acknowledges positive effects of long-term presence, such as bringing nursing to China in the 1880s and changing national healthcare (Chen, 2005).
Cunningham is credited with initiating short-term outreach mission (STORM) in the 1950s with the advent of jet travel (Loobie, 2000), projecting an outreach lasting weeks or months rather than years. The estimated numbers of STORM participants from North America in 1965 was 540. This figure jumped to 120,000 in 1989 and to a half-million by 1998 (Loobie, 2000). Mission no longer required long-term foreign assignment.
The participation trend continues upward, with an estimated 2.5 million outreachers in 2003 (Honig, 2005). As short-term missions increased, the reported number of full-time international missionaries from North America decreased from 65,000 to 35,000 in the period 1988 to 2005 (Lucas, Sterns, & Sterns, 2006). The number of participants in specifically short-term medical missions (STMM) is unclear, but MAP International, a nongovernmental organization provided outreach medicines for 880 medical teams in 2004, estimating 15,840 participants (Dohn & Dohn, 2006).
Nurses have unique roles to play in healthcare internationally, including short-term outreach work (Bajkiewicz, 1999a). Cross-cultural theorist Madeline Leininger (2002) notes that culturally congruent care involves careful consideration in crossing cultures and working abroad. Culturally incongruent care has been linked to detrimental health outcomes and can violate ethical beneficence (Cameron-Traub, 2002). Therefore, what are appropriate nursing activities when a nurse participates in a short-term healthcare outreach internationally?
CURRENT MEDICAL OUTREACH CHARACTERISTICS
The literature portrays three types of STMM work. The first is relief care in complex humanitarian emergencies, for which response-need has tripled over the past decade (Gustavsson, 2006). These emergencies represent the profound absence of basic human necessities, requiring a quick response from the international community to save lives. Relief nurses need to be well trained in disaster care, to function in very difficult circumstances, and to shoulder the high cost of immediate deployment (Duininek & Williams, 2006).
A second type involves surgical-dental teams operating in underdeveloped regions where such services would never be available. Working with national healthcare professionals, teams perform procedures using in-country facilities (Carter, 2004) or hospital ships or planes (Clare, 1996). For the patients, these procedures are life changing and greatly beneficial (Kim, 2005).
With a third type, mobile clinics, teams organize and recruit physicians and nurses, travel to a country, and set up in multiple locations. The diseases and problems treated most often are restricted to uncomplicated conditions or common ailments requiring palliative noninvasive care. Treatment is based on physical exam data, limited laboratory availability, and empirical treatment with pharmaceuticals brought by the team (Dohn & Dohn, 2006). Sometimes referral, if possible, is made for follow-up care with indigenous healthcare providers when treatment is accessible and available. Nurses usually are involved in triage, vital signs, random blood sugar tests, and sometimes actual examination and diagnosis. Mobile clinic work typically reports high numbers provided care in the outreach, with patient outcomes measured as volume of patients seen.
EFFECTIVENESS OF STORM
The actual measured effectiveness in general outreach mission is controversial. Concerns have been raised about the present-day, million-dollar STORM industry regarding a lack of long-term involvement and mixed cross-cultural preparation (May, 2000; Palmatier, 2002; Slimbach, 2000). Much of the literature on STORM has rated effectiveness positive based only on the perceived experience and efficacy of the participants rather than the recipients of outreach, and researchers have focused on participants' perceptions immediately after a mission experience, which are almost always positive (Graves, 1997; Honig, 2005; Ver Beek, 2005).
Ver Beek (2005) compared Honduran attitudes and church attendance after hurricane relief. In this comparison of 30 home-building teams from the United States with 30 local Honduran church teams, no appreciable difference in the perceptions of relief recipients was found. Locals commented that the foreign team would have been more effective by just sending funds, potentially restoring 12 more houses for every team that came.
In a review of 41 articles published from 1986 to 1996 by healthcare professionals reporting on disaster relief, surgical campaigns, and mobile medical clinics, Graves (1997) found no discussion of health improvement in the regions served. Moreover, “positive outcomes” were the personal beneficial value of participation in such trips.
This general focus on participants has contributed to a perception of STORM that may not be wholly accurate. In response, some have proposed a shift in focus to measurable improvements of a locale through the support of indigenous works for long-term regional impact (Priest, 2005).
Regarding longer-term STORM impact, one researcher followed 116 short-term missionaries before, immediately after, and 1 year after a mission experience. Participants' prayer, Bible study, faith community involvement, and evangelism decreased over the course of the year either to pre-experience levels or, in some cases, to below pre-mission trip levels. Pre- and postdiscipleship training, follow-up, supportive families and churches, and involvement in multiple missions mediated this negative decline (Friesen, 2005).
With mixed reports, some have called for a reworking of short-term outreach to adopt cultural exchange features over a longer term (Nah, 2000). A Code of Best Practice in outreach has been forwarded that stresses partnership and agenda setting by national leaders in the host country (The Evangelical Fellowship of Canada, 2000). A U.S. group has created standards of excellence, asking mission-sending organizations to pledge to keep the standards (U.S. Standards of Excellence in Short-Term Mission, 2008).
The effectiveness of healthcare outreach also is controversial, and a gap in the literature exists. A study by Montgomery (1993) followed two medical-dental outreaches in Central America and Mexico, finding negligible improvement in overall community health and possibly harm to some existing public health delivery systems. Freire (1970) reported that interference to the local processes of family, government, and community resources by outside Western relief efforts had negative effects with the poor in Brazil. This impact from outside involvement directly affects the local healthcare delivery system, including local physicians, nurses, and community development workers. In regions with a healthcare network that is frail and under development, the activities of outreach groups, although sincerely desiring to be helpful, can produce undesirable results in the final analysis (Hershberger, 2004).
However, short-term treatment clinics can be effective, furthering the on-site work of the healthcare system and the church. The author was part of week-long medical treatment clinics in Columbia, conducted in cooperation with a number of local healthcare providers, the regional Secretary of Health, and a group of national and missionary church planters. National providers and visiting practitioners worked side by side, sharing practice knowledge and building relationships. The clinic saw more than 1,500 patients, many of whom were connected on site with the regional providers for follow-up care. A number of the patients returned for the evening evangelistic services and came to know Jesus Christ through the event. A decade later, a thriving church remains as a result of the cooperative partnership.
Michael and Anita Dohn, long-time missionaries working with healthcare teams, describe how consultations and treatments offered by visiting medical professionals from Western countries can be in conflict with the treatment of local physicians and healthcare workers, who know the conditions and available therapies in their region (Dohn & Dohn, 2006). The Dohns remind that the nature of STMM is relief work, not development. Outreach goals should be realistic to the few days spent with a community, and outcomes should not be overstated. International relief work must preserve local on-site ownership for real health development and positive outcomes (Ramstad, 2003; Ferranti, 2002). Fountain (1996) noted that effectiveness with the people of Zaire was based on addressing worldview, not simply providing knowledge, treatment, or technology, and that cultural understanding leading to positive health outcomes can be obtained only by long-term engagement.
A multidisciplinary working group currently is developing best practice statements with regard to short-term medical missions (http://csthmbestpractices.org). The group hopes that these statements will reflect recent World Health Organization and United Nations Children's Fund (UNICEF) standards for faith-based works abroad (G. Tazelaar, personal communication, December 16, 2008).
TOWARD EFFECTIVE MISSIONAL NURSING
Nurse author and theologian Judith Shelly (2004) has pointed out that key elements of Jesus' sending call to nurses were to make disciples and to teach. New Testament discipleship requires long-term commitment and engagement. Given this context, what activities and interventions would nurses find effective in short-term medical outreach work?
Teaching may be the nurse's most effective role in missions currently. Embracing the roles of health educator and colleague to national healthcare workers can aid the development of effective patient education efforts and have a positive impact on a community far beyond the short-term trip.
Overall, nurses are well qualified for teaching and training in health but require preparation for cross-cultural education (Tazelaar, 2001). This includes researching the predominant language and culture, knowing prevailing health issues of the region, learning from local practitioners, and clearly using educational materials to match the literacy and cognitive processes of learners (Ward, 1993).
The international nursing honor society, Sigma Theta Tau (2005), has issued a position on global health and nursing research, indicating a desire for greater involvement and international exchange with nursing structures around the world. Creating connection and exchange with nurse training programs in underdeveloped countries, even on short-term trips, could have a great impact on global and regional nursing care while supportive relationships are built with colleagues abroad. Such exchanges by individuals and schools of nursing could greatly advance the global perspective and experience of students, faculty, and practitioners.
During any outreach, direct patient education should be a component, but given by or with nationals for the greatest effectiveness (Dohn & Dohn, 2006). Nurses should work with nationals to deliver education properly and be available as a resource during and after outreach. Leaving copies of visual aids with nationals can be an effective long-term equipping strategy, as was found with oral rehydration education for children (Bajkiewicz, 1999a). Health education teaching during short outreach trips has been found to make some impact on the health of poor families in Haiti related to common illnesses (Brakke, 1997).
Without the public services familiar in the West, underdeveloped regions have unique needs for basic health education. The Millennium Development Goals (MDGs) of the United Nations (2005) articulate eight focus areas of need, with specific and measurable objectives. Sigma Theta Tau (2005) promotes the MDGs as a nursing and research priority. To realize the goals, the United Nations Children's Fund (UNICEF, 2002) has a comprehensive body of education called Facts for Life, a readily available and proven curriculum for training community development workers or conducting community health education, both effective nursing activities abroad (Crigger & Holcomb, 2000).
For effective healthcare delivery, Western nurses will need training in the realities of underdeveloped regions. An increasing focus on community health development and education has been suggested for better meeting health needs abroad (Fountain, 2004; Hershberger, 2004; Tazelaar, 2001).
Forming long-term, committed exchange between Western nursing programs and nurse training in underdeveloped regions is a critical need. Such exchange can further nursing practice and research in a reciprocal fashion. Assisting faculty, training new care techniques, and providing a supportive presence abroad, in humility, can build community and bring great encouragement (Hershberger, 2004). Educators in developing countries relay a desperate need for qualified nurse educators from Western countries to come and assist with undergraduate and graduate education of nurses (J. Shelly, personal communication, October 28, 2008).
Extending a short-term outreach from a 10-day trip to a month in country could radically change the STMM dynamic and accomplish greater benefit to all involved (Nah, 2000). This is true when education and partnership building are the nurse's goal abroad, and both require time and proximity (Bajkiewicz, 1999b; Miller, 2004). Increased time would allow for (a) proper cross-cultural engagement of the nursing process, (b) development of a careful and appropriate community assessment and plan before any intervention, (c) more focus on the recipients of care, and (d) outcome research for better guidance of practice. Returning to the same location repeatedly would engender true long-term relational and communal missional work between two communities and cultures.
In the Gospels, Jesus was a cross-cultural learner before implementing interventions. Nurses should consider their first trip to any underdeveloped region as a learning experience. They should build relationships first and foremost, then build on what they can do by attempting to return to a country again and again. There is no greater joy than connecting well with others across cultures, which is the essence of missional nursing.
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