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Safety measures for nurses working abroad

Moore, Amy, DNP, APRN, FNP-C; Opton, Laura, DHSc, RN, CNE; Thal, Wendy, DNP, APRN, FNP-C

doi: 10.1097/01.NME.0000559592.04244.27
Department: On the Horizon
Free

At Texas Tech University Health Sciences Center School of Nursing in Lubbock, Tex., Amy Moore is an Associate Professor of Nursing and the Director of Global Health, Laura Opton is an Associate Professor of Nursing and the Director of the Second Degree Program, and Wendy Thal is an Associate Professor of Nursing and the Director of the Rural and Global Health Certificate Program. All three authors are active in global health excursions with interprofessional faculty and students.

The authors have disclosed no financial relationships related to this article.

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As educational institutions, governmental agencies, and nongovernmental agencies increase their presence in global health activities, nurses are on the frontlines applying their expertise to help those in need. If you have a passion to volunteer to work in a foreign country, you must be aware of safety measures to prevent mental and physical harm to yourself while serving others. Immunizations, strategies to minimize culture shock and depression, knowledge about common diseases and travel advisories, and resources for emergencies should be part of your plan before you travel.

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Health of the volunteer

The CDC travelers' health website provides excellent up-to-date information about staying healthy while traveling abroad (see Resources for planning a medical mission trip). In general, if you're traveling to provide medical care as part of a mission to a developing nation, you're going to be at higher risk for health problems because these regions often lack infrastructure and resources. Planning ahead is important to minimize risk.

Most US healthcare providers are up-to-date on routine vaccinations, such as tetanus-diphtheria-acellular pertussis and hepatitis B, but they may not have the vaccinations recommended for international travel, such as hepatitis A and typhoid. Vaccination recommendations vary based on locale, so it's best to check with your primary care provider as early as possible in the planning process to start needed vaccination series. Some countries have vaccination requirements, such as for yellow fever, which require you to go to a travel specialty clinic for administration. If you're an adventurous eater, you may also want to consider getting vaccinated for foodborne illnesses.

During the planning process, consider your unique healthcare needs. Do you have a chronic illness that requires routine medications? Do you have a health condition that requires durable medical equipment, such as an oxygen compressor or a wheelchair? Are you pregnant or thinking of becoming pregnant in the near future? Consult with your primary care provider to discuss specific concerns. It's stressful to realize in the middle of the trip that your physical condition isn't as optimal for travel as you thought it would be. If possible, increase your exercise and endurance beginning several months before your trip.

When traveling with medications, it's best to research whether they're legal in the country you're visiting. Keep the medications in the original prescription bottles and have a medication list from your primary care provider with them. Pack medications in your carry-on luggage in case your checked baggage is delayed. Keep a backup list of medications and general healthcare information in your suitcase for unanticipated trips to the hospital. If you plan to bring durable medical equipment, be sure that it's approved by the Transportation Security Administration and you'll be able to use it at your destination. Many foreign countries aren't Americans with Disabilities Act accessible, so have a backup plan in place if you require assistance.

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Culture shock—a sense of disorientation when exposed to an unfamiliar culture—is real and can leave you unsettled and depressed even during a short mission trip. Culture shock results from anxiety experienced when surrounded by unfamiliar things, such as foods, smells, language, and social customs. Particularly difficult situations, such as caring for a gravely ill child, may increase the potential for culture shock. It can be helpful to discuss problems you're having related to the culture or environment with local missionaries.

When you return home, it isn't unusual to experience culture shock in reverse. You may feel sad, withdrawn, and have an overwhelming desire to return to the site to continue your medical work. You may have thoughts of returning to “save everyone.” You may also be surprised that while telling friends and family about the trip, they aren't as interested in your experiences as you are. Plan to set times for debriefing with team members to share thoughts and feelings about the day's events and draw on more experienced team members as a resource. Debriefing throughout the trip and afterward with others who've had the same experiences helps prevent or resolve feelings of depression.

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Safety and security

The US Department of State shares security information for all countries, assigning travel advisory levels between 1 and 4. Level 1 is the lowest safety and security risk, advising normal precautions. Level 2 advises increased caution. Level 3 advises to reconsider travel and Level 4 advises to avoid travel due to potential risks. The different levels provide a rationale for the assigned advisory level, including crime, terrorism, civil unrest, health, natural disasters, and time-limited events. A country's assigned security level can be misleading because, on occasion, a small portion of a country may have an issue, such as health problems or increased crime, whereas the rest of the country requires normal precautions. The US Department of State's website is an excellent resource to evaluate the safety of different regions when considering travel.

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Safety advice varies by country. In some areas, eating food from street vendors can be life threatening for a traveler due to lack of clean water or other hygiene factors. Be careful even taking fruit from a vendor on the side of a road. You should rely on the group hosting the medical team to identify safe foods to eat and the safest restaurants at which to eat.

Walking at night or alone can also be dangerous in even the safest countries. It's much safer to explore the region on foot via small groups and during daylight hours to minimize safety risks and discourage mugging, injuring, or kidnapping. Take extra precautions when walking around the town/city if there are no traffic lights or stop signs.

Research the most prevalent diseases and the transmission of those diseases in the country you're planning to visit. For example, if you're going to Central America where there's a high rate of Zika virus, take and use mosquito repellent. There are also different times during the year that certain diseases are more prevalent, such as an increase in Zika virus during the rainy season. In addition to practicing universal precautions, you need to understand how to best protect against disease transmission for the region's most prevalent diseases.

Other types of protection may seem obvious but are just as necessary to keep you safe. Obtain evacuation and medical insurance if your insurance doesn't provide coverage in the country you're visiting. Wear sunscreen if you're going to be in the sun for any length of time. Get plenty of rest and eat a well-balanced diet because irregular sleep patterns, poor eating habits, and excessive alcohol intake can increase the probability of becoming ill (see Additional safety measures).

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Ethics

Literature concerning ethical practice when planning or participating in international medical trips has increased in recent years, revealing the popularity of medical mission trips and the importance of developing appropriate guidelines based on ethical principles. The focus of these trips should be on improved outcomes for everyone involved (in-country and visiting healthcare teams, patients, families, and communities), with the incorporation of concepts related to social justice, equality, and collegial collaboration. Good intentions can create harm if there's a lack of understanding regarding the impact of the medical trip beyond the time spent in the country.

There are four principles that promote the development of ethical international medical programs: involving the host country in trip development, demonstrating respect, training appropriately, and considering sustainability (see Four principles for ethical international medical programs). The initial planning phase of any medical trip should include reaching out to the target community to identify what's needed or wanted, such as performing a needs assessment, evaluation of healthcare needs, and capacity building. Partnerships with local groups and healthcare providers should be considered, along with how to ensure sustainability of the program and follow-up for care provided. Education should be an integral part of each trip and can be reciprocal so the in-country and visiting healthcare teams can learn from each other, promoting respect for other people, cultures, and healthcare practices. Best practices and standards of care should be followed, and individuals shouldn't be allowed to perform any skills for which they aren't trained or that they wouldn't be allowed to do in their home country. Everyone should practice within their scope.

Harm can be done when medical team members aren't provided with adequate cultural knowledge to prepare for the trip. One of the most detrimental aspects is when team members ascribe stereotypes, which create the illusion that “they” have problems “we” can fix because “we” have education and “they” don't.

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Rewarding service

Participating in global health excursions can be rewarding in many ways. Many nurses who experience caring for others in low-income countries often return multiple times, providing primary care, educating healthcare providers, and developing long-lasting relationships with others abroad. Nurses who have a desire or “calling” to participate in these trips should accept the challenge but always take the necessary safety precautions.

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REFERENCES

Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. Trop Dis Travel Med Vaccines. 2017;3:5.
    Mishori R, Eastman A, Evert J. Improving the safety and security of those engaged in global health traveling abroad. Glob Health Sci Pract. 2016;4(4):522–528.
      US Department of State Bureau of Consular Affairs. https://travel.state.gov/content/travel.html.
        World Health Organization. International travel and health. http://www.who.int/ith/en.
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