Ethics and global health outreach programs

Author(s): April Beckling, MSN, RN, CMSRN, and Kamie Parks, MSN, RN, NP-C

Plan ahead to ensure a successful and respectful experience.

Takeaways:

  • Embarking on a global health trip includes both logistical and ethical considerations.
  • Preparation before a global health trip will help ensure you work within your scope of practice and understand how to address ethical concerns.

Participating in global healthcare may be one of the most rewarding experiences of a nurse’s career. Taking your knowledge and skills to a place where you’re desperately needed can provide personal fulfillment and satisfaction, and your efforts may significantly improve the community you’re serving. But to ensure your overall impact is positive, you’ll need to consider many ethical and logistical questions.

Global health outreach programs

In many developing countries, a disparity exists between healthcare needs and healthcare availability and affordability. Global health outreach programs (GHOPs) seek to reduce this disparity by providing short-term (less than 6 months) assistance to local citizens, many of whom live in rural communities with limited access to healthcare for a variety of reasons, including lack of finances and long distances to clinics.

When participating in a GHOP, you’ll work with the local healthcare team to care for and educate people with a range of conditions, including urinary tract infections, sexually transmitted infections, hypertension, diabetes, and obesity. You might administer basic medications, and you’ll provide healthcare education tailored to the local community’s access to equipment and medications and individual citizens’ education levels. This healthcare education frequently is provided through a health fair.

Setting the framework

Setting the framework for healthcare provision in a foreign country requires preparation and planning. What are the licensing and country regulations? Do you understand your scope of practice within your home country and the receiving country? Local ministry of health or chief nursing offices can help GHOP leaders and nurses understand the host country’s overall healthcare needs and goals, which can serve as a planning guide. Teaming up with local healthcare leaders also may help focus efforts where they’re most beneficial. Hands-on healthcare is the main goal of most GHOPs, but they also provide education to professional healthcare workers, community healthcare leaders, patients, and citizens. In return, volunteers can learn powerful lessons from local healthcare workers and community members.

Before departing for your GHOP trip, research the host country to gain an understanding of its guidelines and regulations for providing healthcare. For example, you may need a temporary license, which will take time to acquire. Also investigate the healthcare infrastructure and strive to understand its hierarchy of healthcare professionals so you can better fit in. Some areas of study or certifications may not be recognized in the same way as in your home country. You must stay within your scope of practice while providing any type of healthcare in your host country. A good rule of thumb: If you aren’t trained, licensed, or certified to perform certain skills (for example, prescribe medication) in your home country, then you shouldn’t perform them in your host country. (See Be prepared.)

You also should keep in mind that you may not have access to safe drinking water, working toilets, or electricity.

Be prepared

The American Nurses Association (ANA) position statement on the ethical considerations for local and global volunteerism recommends that nurse volunteers should:

  • reflect on reasons for volunteering
  • review the sponsoring organization’s ethics statement to ensure agreement of views prior to agreeing to volunteer
  • look into the sponsoring organization’s reputation
  • partner/collaborate with host communities by communicating and planning before the experience and while on-site
  • evaluate the experience with the host community and the sponsoring organization
  • perform/work within their scope of practice regardless of the location and purpose of the activity and with local professionals’ consent and supervision
  • confirm and comply with the host country’s licensing and practice regulations
  • consider motives for taking photos and the feelings/emotions of those in the photo
  • avoid posting photos on social media or using them in public presentations without permission
  • understand and use the chain of command or appropriate reporting authorities
  • recognize ethically problematic situations and anticipate associated moral distress
  • be aware of post-volunteer reactions and attend available debriefing sessions with other volunteers.

In addition to the ANA recommendations, ask yourself these questions as you consider whether you want to participate in a global health outreach program (GHOP):

  • Does the sponsoring organization have a proven history in the area? Is it a nonprofit entity? A sponsoring organization can help ensure you’re in a safe area and will maintain contact with the citizens after you return home. A nonprofit’s priority will be serving the community’s physical and spiritual needs, not financial profit.
  • Is a local healthcare governing body sanctioning or supporting the trip? Never provide care without permission. The local healthcare governing body can help mitigate challenges you might face with customs and local authorities.
  • If translators are needed, are they provided? If your GHOP members aren’t fluent in the local language, the sponsoring organization can help obtain translators.
  • Who is providing medications or durable medical supplies? Medications and equipment (such as nebulizers, lab testing equipment, cleaning supplies) can be expensive to purchase and transport for individual volunteers. Planning is required to ensure the trip is financially feasible for GHOP participants.
  • Is it safe for me to go? Consider your own limitations to travel and the safety of the area you’re traveling to; check travel advisories for the region.

Potential ethical dilemmas

GHOP novices may encounter unexpected ethical dilemmas, including limited ability to provide care, patient privacy challenges, and cultural and practice differences.

Best practices/care access

Before your trip, speak with the GHOP you’ll be working with to learn about the community’s current access to care and how it may differ from your current practice; the best practices you’re accustomed to may not be fol­lowed or available.

In addition, you may see many more citizens than you could ever hope to treat, which means you might have to close clinic doors while a line of patients is still waiting to be seen. Although not all clients can be seen, the healthcare education you provide will spread long after the GHOP has ended.

Patient privacy

Keeping client information private can be difficult because of site challenges, such as no private exam rooms and the need for translators. Seek privacy during invasive physical exams and difficult conversations with clients. Most patient documentation (exam, treatment, and care) will be handwritten because of a lack of electronic health records and can easily be lost. Keep records in a safe location and plan to give them to the local healthcare system when possible to ensure continuity of care.

Personal beliefs

Reconciling your personal beliefs with the local community’s norms may be challenging. For example, a client’s religious beliefs may make him or her resistant to safe sex practices or the local culture may limit women’s rights. Be kind and respectful; you don’t want to impose your beliefs on others. Identify a confidante (possibly a member of your GHOP) you can speak with about your feelings.

After you leave

When providing care in a foreign country, you need to consider what occurs after you leave. For example, who will manage a client’s care when you’re gone? This is particularly important when it comes to medications. For example, providing 30 days’ worth of antihypertensive medications to a client who doesn’t have a source to obtain a refill can be dangerous. And what if the client has an adverse reaction to the medicine? Who will evaluate him or her? In the case of many psychiatric issues, you’ll need to arrange for follow-up counseling because you won’t be able to address the client’s needs in the short time you’re in the country.

You also need to beware of unconsciously undermining clients’ belief in their own healthcare authorities; they should have faith in the country’s healthcare system after you return home. If you’re a prescriber, order medications that local providers have the capacity to give. It makes no sense to change a client’s oral hypoglycemic drug from one brand to another based on the GHOP provider’s preference when the client can’t obtain the new medication. The client may perceive the change in medication as the GHOP provider not agreeing with the local provider and may decide to stop seeking medical help from the local authorities. When the GHOP leaves, the only one available will be the local entity, and clients must be able to believe in their healthcare providers.

Partnering with your GHOP and the local healthcare officials, planning ahead, and respecting local belief systems and cultural norms can facilitate a smooth care transition. Ideally, when you leave, local citizens should feel empowered to take ownership of their healthcare.

Nurse benefits

Participating in a GHOP provides you with an opportunity to experience other cultures and gain new perspectives about healthcare infrastructure in countries around the world that will contribute to your personal and professional growth. The gratitude of the people you serve can be nearly overwhelming and leave you with a profound sense of having made a difference in their lives. This feeling will follow you home and may help reinvigorate your work as a nurse.

Do no harm

As more healthcare professionals participate in global health, considering potential ethical dilemmas is important. Are we really leaving communities better than we found them? If not, how do we make the necessary changes to ensure improvement rather than harm?

The authors work at Texas Tech University Health Sciences Center School of Nursing in Abilene. April Beckling is an assistant professor, and Kamie Parks is an instructor.

References

American Nurses Association. Position Statement: Ethical Considerations for Local and Global Volunteerism. 2019. nursingworld.org/~4a346d/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/social-causes-and-health-care/ethical-considerations-for-local-and-global-volunteerism_final_nursingworld.pdf

Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. Trop Dis Travel Med Vaccines. 2017;3(5). tdtmvjournal.biomedcentral.com/articles/10.1186/s40794-017-0048-y

DeCamp M, Soleymani Lehmann L, Jaeel P, Horwitch C. Ethical obligations regarding short-term global health clinical experiences: An American College of Physicians position paper. Ann Intern Med. 2018;168(9):651-7.

Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond medical “missions” to impact-driven short-term experiences in global health (STEGHs): Ethical principles to optimize community benefit and learner experience. Acad Med. 2016;91(5):633-8.

St Clair NE, Pitt MB, Bakeera-Kitaka S, et al. Global health: Preparation for working in resource-limited settings. Pediatrics. 2017;140(5): e20163783. pediatrics.aappublications.org/content/140/5/e20163783.long

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