Nursing in Diverse Cultures: an international experience.
Subject: Nursing schools (Services)
Nursing schools (Social aspects)
Student service (Methods)
Nursing students (Beliefs, opinions and attitudes)
Nursing students (Social aspects)
Author: Axley, Lawrette
Pub Date: 03/22/2009
Publication: Name: Tennessee Nurse Publisher: Tennessee Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2009 Tennessee Nurses Association ISSN: 1055-3134
Issue: Date: Spring, 2009 Source Volume: 72 Source Issue: 1
Topic: Event Code: 360 Services information; 290 Public affairs
Geographic: Geographic Scope: Dominican Republic Geographic Code: 5DOMN Dominican Republic
Accession Number: 197809908
Full Text: Each fall and spring nursing students and faculty members from the University of Memphis, Loewenberg School of Nursing, trade the comforts of home for the opportunity to make a difference in the healthcare of individuals and families in the Dominican Republic. Nursing students, faculty and registered nurses in the community recognize the need to create a service learning opportunity and expand the classroom to the global health environment. Participation in the Nursing in Diverse Cultures program has continually grown since 2005. Nurses and students provide basic medical care and health teaching to highly impoverished families in the some of the poorest areas in the Dominican Republic.

Service learning strategies used in the Nursing in Diverse Cultures program integrate meaningful experiences with traditional instruction with opportunities for applying personal responsibility and critical reflection. Participants in the program provide care while cultivating an understanding of the cultural dimensions of family, community, and health. The program is designed as a service-learning program with the goals of providing culturally competent healthcare and health teaching while working mano-a-mano "hand in hand" with the community leaders, physicians, and teachers in the country. This work in the Dominican Republic is made possible through a strong collaboration with the Foundation for Peace (FFP), a not-for-profit organization dedicated to enabling personal and community achievement for Dominican families. The Foundation offers leadership for groups to provide direct medical care and health education to Dominican and Haitian communities in partnership with local physicians and medical staff. The FFP maintains ongoing communication with the Dominican Consulate of Health who approves visiting practitioners. The Foundation also obtains the needed approval from customs in order to bring in medical supplies to be used in the medical clinics. In addition to the medical mission service, each year, FFP assists a variety of churches and other groups from the U.S. who wish to participate in mission trips co-led by FFP staff members.

Facts about the Dominican Republic

The Dominican Republic is located on the eastern two-thirds of the Caribbean island of Hispanola and shares a western border with Haiti. According to the U.S. State Department, the country has a population of approximately 9 million people and many live in extreme poverty with an estimated yearly income of less than $7,000 in U.S. currency. Approximately one-half of all Dominican people live in rural areas in small communities. Adverse conditions in the Dominican Republic promote diseases such as malaria, parasites and nutritional deficiencies among children and adults alike. Although the Dominican government provides standard medical care to its citizens, the quality of care is limited. This is particularly true for individuals living in the remote locations outside of the capital city, Santo Domingo. In rural communities, individuals have limited access to health care. If they can obtain transportation to see the healthcare provider, funds for purchasing medication are often unavailable. The poverty experienced by a significant portion of the population is often cyclical in nature. Dominican families often lack enough food for the entire family and every adult must work. With everyone working, the children are denied the opportunity to attend school; they are often the last to receive food and medical care. Children typically marry early, have children at a young age, and continue the cycle of poverty through the generations.


Advance Preparation

Preparation for the service learning experience in the Dominican Republic begins with the application process. Each participant must reflect on personal and professional goals related to developing cultural competence. For first time participants, the goals often relate to helping the underserved population in the Dominican. Returning participants spend more time visiting in the homes, experiencing the culture, and developing relationships with people in the communities. For many individuals, the concept of culture relates only to the difference in ethnicity, dress, diet, and language. In reality, cultural competence is multi-dimensional, requiring an understanding of cultural awareness, knowledge, skill, and personal encounters. Participants must take time to reflect on personal feelings and begin to recognize differences prior to their arrival.

Each participant pays individual travel expenses; in addition, students pay university tuition. While initially costs were considered a potential barrier, increased interest and course enrollment suggest otherwise. In fact, students value the learning opportunity so much that they elicit financial support from family, friends, and community sponsors to cover course tuition and travel expenses.

A key factor to the success of the service learning experience is preparing students for the expected and unexpected. Students prepare to forfeit many of the comforts of home, such as hot showers, readily available water, and air conditioning, often taken for granted in the U.S. Studying and working conditions in the Dominican Republic include the hot, humid climate, which challenges both students and faculty. The first item listed on the packing instructions that each person receives is flexibility which is guaranteed to be the most used item of all!

The community settings designated for nursing clinics are chosen in advance of travel by local FFP missionaries who maintain ongoing relationships within the country. At the clinic location, the day is spent addressing basic health needs and concerns of individuals and families. Working with the local people is important as they assist in setting up the supplies; they organize and conduct registration which includes gathering brief demographic information, specific health needs, and family concerns. The clinics are make-shift and primitive by developed country standards. Fold up tables, cotton bed sheets, twine, and safety pins are carefully laid out to form the waiting area and "consultoriums," or examination rooms.

Students have prepared for the various health conditions common in the Dominican Republic. In addition, students collect supplies such as hygiene items, over-the-counter medications, and selected prescription drugs to use in providing health care. All supplies are listed in a detailed inventory and are re-packaged for travel to meet the requirements of the international customs bureau. Although textbook descriptions and pictures of common problems are reviewed in advance, the actual presentation of diseases and symptoms rarely match up perfectly. The students see many needs they would not see in the U.S. Most of the Dominican people have parasites, poor nutrition, and daily chronic pain, with little hope of ever seeing a doctor for treatment. The nursing students see how health care is negatively impacted by inadequate nutrition and extremely poor economic situations of a third world country.

Patient Encounters

Everyone seen by the nurse is treated with parasite prophylaxis (duration is 90 days) and multi-vitamins (90 day supply). Common health problems seen in the medical clinics include gripe' (cold/sinus), estomago' (stomach problems), and dolor (pain). Teaching topics include the importance of washing hands and drinking purified water. Student nurses, using elementary Spanish and Creole with the aid of paid interpreters, communicate with the people who come to the clinic; lives begin to change. For most clinical encounters, the family is seen together as a unit, which allows an integral connection to occur between the nurse and family. Often family members will discuss the needs of their neighbors, friends, or other family members of the community as one close relationship.

At the conclusion of the assessment and teaching, each family receives supply packs prepared by the nurses from donated items that include bars of soap, dental products, wash cloths and toiletry items. In situations of acute illness such as infections, draining wounds, or dangerously high blood pressure, one of the nurse practitioners is consulted to determine the need for medication. If the condition is of a chronic nature, such as hypertension or diabetes, the practitioner will counsel the families about access to healthcare and the need for follow-up by local physicians. Often an individual arrives at the clinic with an old, dingy piece of paper with the name of a medication written on it. With further discussion the translator reports that the patient had seen a local doctor who visited their community; however, the patient had no money to purchase the medicine. When possible, the medication is provided from the clinic supplies as appropriate by the supervising nurse practitioner. Often medical mission teams are the patients' only access to health care. The care team tries to give the patient enough medicine to last until another team comes again.

Student Reflections

Evenings at the hotel call for showers and sustenance. The heat of the day has left everyone in sticky scrub pants and T-shirts. Even in the hotel, the showers can be cold because of a shortage of warm water. The frequent loss of electricity may leave everyone dressing in the dark and without the luxury use of a hair dryer. Yet, the events and encounters of the day continue to sustain the team. Following the evening meal, a time of sharing and discussion, guided by the nursing faculty, focuses on debriefing the experiences of the day; for many students, this is their first time to see such impoverished conditions and come face-to-face with so many unmet needs related to rampant disease and illness. Discussion time is crucial to allow exploration of culture and varying degrees of culture shock. The experiences are rich in learning and contribute positively to the development of cultural sensitivity and competence for both student and faculty participants. A common concern consistently voiced by the students is their felt need to do more and provide more for their new Dominican friends. Students describe the inequities they witnessed and find it difficult to understand how the Dominican people remain joyful and loving, while lacking for what Americans view as necessities.

As part of the course requirements, students journal about their daily encounters. One student wrote, "What struck me most about the people is that they don't complain. They light up when we greet them or stand to shake a hand, and they grow taller; sit to talk to them and they open up with smiles and tell you whatever you ask. They are so happy to have us here. It's really amazing."

The following journal entries provide a glimpse into the nurse-family clinic encounters.

Encounter 1: We treated young man who had chopped his foot with an ax, it was badly infected from keeping it in a sneaker, all that moisture, bacteria and dirt ... hopefully it will heal and he'll keep his foot.

Encounter 2: In the Dominican Republic, some of the people were unaware of the connection between unsafe drinking water and parasites. One thing I found interesting about this trip was the way families interacted with each other. The family unit was not just parents and children, but one big extended family with at least three generations coming to the clinic together. I remembered this about the Hispanic culture from our classes, but it was interesting to actually see it.

Encounter 3: I have new respect for the Dominican people. To manage as well as they do with the poverty and adverse environmental conditions they must live with is remarkable. I could never have this respect and understanding without the experience of actually being there. A nurse can't fake respect and empathy. We can read about and talk about other cultures all we want, but in order to truly have the respect and understanding to deal with the immigrant population in the U.S. we need to know what they have grown up with and what they have left behind to get here.


The global service learning experience often has long-lasting influences. Students improve their communication and listening skills, develop better skills of patient assessment, learn to rely on their clinical judgments in consultation with faculty, and increase their knowledge of diseases prevalent in the developing world with limited resources. Anyone interested in developing or participating in an international service learning program can find an organized group for almost any country and length of stay. The best plan is to first go on a trip as a participant. Realize that working conditions may be primitive; even with the best steps in planning, supplies will still be limited. Participants will likely face health and social problems they cannot change in a short term project. Look for organizations with sustainable programs as this allows for coordination and ongoing service to the communities. Finally, remember who nurses are and what nurses can do. Think frequently about nursing as both an art and a science. The international service learning experience embraces this fundamental characteristic of nursing that can often be difficult to articulate.

by Lawrette Axley, PhD, RN, CNE Assistant Professor, Nursing Loewenberg School of Nursing The University of Memphis

Lawrette Axley, PhD, RN, CNE, is the recipient of numerous teaching awards and honors, including the University of Memphis' 2006 Thomas W. Briggs Excellence in Teaching Award. She is a National League for Nursing Certified Nurse Educator (CNE). Axley is the coordinator for the first level nursing courses. She teaches Foundations of Nursing, and co-teaches Clinical Pathophysiology. She also teaches the Nursing in Diverse Cultures course which includes an international study experience to the Dominican Republic and provides ongoing leadership for the bi-annual medical mission trip there.
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