Community Health Development: A realistic goal or a pipe dream

Problem   Should Short-term healthcare mission team members obtain licenses to practice within a host country?   Consider the following report. A local doctor arrested this month in Zimbabwe on charges of practicing without a license during a mission trip was released this week, say officials. Dr. Ed Montgomery and his wife, Sara Jane, a nurse, have both been given back their passports, confirmed Senator Mitch McConnell's office Tuesday. The pair had been relieved of their passports approximately two weeks ago while on a medical mission trip in the African country. According to his friends, Dr. Montgomery had been looking forward to the trip with friends. A retired urologist, Dr. Montgomery and his wife had participated in several other medical missions around the world.   According to Dr. Montgomery's former partner, Dr. Scott Scutchfield, after Dr. Montgomery's charges were dropped he headed with his wife to South Africa.   Julie Adams, deputy press secretary for McConnell's office, said the doctor had worked with the embassy and Zimbabwe officials to obtain a license to practice in that country and hence the charges were dropped. It was definitely a happy ending, said Adams. For the friends and family waiting at home for the Montgomerys, the couple's release comes after days of prayer and concern. "I'm thankful to God," said Scutchfield, after many prayers and well wishes were sent their way from the medical community. "Everyone will be relieved.” Family friend Dr. Chris Jackson also applauded the good news, and those who had helped to bring it about. "We're very pleased for all the efforts made for us," said Jackson, including the help of the newspapers and politicians. The recent news was "wonderful," said Jackson. "I can't wait to get him home." (BURTON, 2004)   We might also consider how we, as healthcare professionals in the United States would respond if we were to reverse the situation.  How would we respond if a group of doctors and nurses from Myanmar came to the United States and started holding medical clinics at a local church?    Research   Health Professional Regulatory Agencies   One of the central tenants held by the patient in the healer-patient relationship is that the healer is skilled and trustworthy. In developed countries there is an increased emphasis on licensing and competency assessment so that the patient can be assured that a healer has at least the basic knowledge needed to successfully manage health-related problems.  End of training examinations, board and sub-board examinations have long been a standard to assess competency. Boards act to screen-out individuals who need to study more or may be poorly suited for medicine. (Hechel, 1979)   Nursing, Psychology, Dental and Medical Boards regulate professional licenses. In some countries, like the United States, the regulatory bodies function at the state/province level making it such that a healthcare professional’s license is only valid in the state in which it was issued. Professional boards not only provide the initial license, but ensure that a practitioner participates in continuing education on a yearly basis. Demonstrating one’s current license to an employer is the only means by which one will be allowed access to provide care in a hospital or clinic setting. Without the license the individual cannot be employed in the United States. (Johnson, 2005)   Care provided by medical missions must meet the legal requirements and medical standards and practice guidelines of the host country. Until relatively recently, very few standards and guidelines were available, and those were rarely enforced. Over the past several years, numerous standards and guidelines have been established for the care of patients in developing countries.  Just as in the U.S.A. where harsh penalties exist for practicing medicine without proper permission, developing countries are beginning to enforce licensure requirements.   Solution   Country/State Specific Requirements for Practice   So we are increasingly asked: “How and where do I apply for a license or legal permission to practice in _______?”  Until relatively recently this question was very difficult to answer, as just as in the U.S.A., the contact information and licensing requirements are often different for different states or regions within the same country.   Fortunately for medical professionals, this information is now provided by the International Association of Medical Regulatory Authorities (IAMRA), www.iamra.com.  This site provides very important contact information for obtaining licensing/legal permission to practice medicine in host countries.  The site includes an “International Directory of Medical Regulatory Authorities” to assist medical regulatory authorities in the exchange of important physician information. The directory provides core information for all known medical regulatory authorities, such as addresses and communication sites/portals, as well a brief description of the legal authority by which the organization received its regulatory powers and the regulatory services provided by the organization   For nursing, the International Council of Nurses, www.icn.ch, maintains a list of nursing councils and their contact information.  Contacting the nursing council for the host country will help begin the process of obtaining a license.  Nurses going on short term trips can often be given a temporary license.  For nurses who seek to practice longer term in country, there may be additional education and practice requirements, such as midwifery, that are not included in basic nursing education in the US.  Expatriate nurses wishing to practice nursing in the US are required to demonstrate that they have graduated from an approved nursing program and met the licensure requirements of the country of origin, or pass the NCLEX examination in the US. (Mc Dougal, October 2011)  Likewise US nurses going abroad should respect their host country’s nursing authorities.   Case in point   Arriving in Uganda in 1985, during the middle of the civil war, neither my sending organization nor my host organization encouraged me to pursue getting a nursing license to practice.  Our community health development work operated in close cooperation with the district health office.  I was told by the district medical officer that a license was not required.  Still I persisted.  I learned where the nursing council who regulated nursing practice was located in the capital city of Kampala.  On my next trip to the capital, I went there with my documents.  The director looked at my documents and thanked me for pursuing a nursing license.  She said that not many expatriates respected the efforts of the Ugandan nursing council to regulate nursing practice and that enforcing their regulations on expatriates was difficult, especially during the war.  Then she confessed that she really didn’t have a reference for how to evaluate American nursing education and licensure.  Having been involved in nursing education in the US, I explained the various nursing education programs that led to professional licensure.  She was so grateful and gave me my license.    Later, when the war had ended, I received an invitation to work with the Ministry of Health in Uganda to revise the nursing curriculum and again several years later to work with them to begin the first baccalaureate nursing program in East Africa.  If I had not pursued getting a nursing license, I would never have been offered the opportunity to come along side of the Ugandan nursing leaders to advance nursing education in my host country.   Conclusion   Recommendations.   1.  The BEST practice is to obtain appropriate licensing in the host country for each team member. Although time consuming, it places the team on a firm footing within the country   Given the coordination requirements, it would be best if the team leader(s) and the Church/sending organization take initial responsibility for this task.  It is important to discuss this issue with the in-country partner early so they can communicate with the host governing authorities regarding visiting healthcare teams.  Healthcare professionals going on the short term missions projects should be ready to submit their credentials – educational transcripts and/or licenses to practice – to the sending organization and/or in country partner or host governing authority.     If the in-country partner is not engaged professionally in providing healthcare, it is inappropriate to assume that they will be knowledgeable about licensing issues for expatriates or that they will automatically take responsibility for obtaining licensing/permission to practice.  For example, groups that partner with churches, orphanages, or economic development programs in host countries, should discuss with their host organizations the importance of getting permission for visiting teams to practice their professions while in country.   2.  A BETTER practice when the healthcare professional is unable to obtain official licensing is to obtain approval through local authorities who are in a position to approve team practice.    Some partners, particularly in creative access countries, may indicate that obtaining licenses brings greater scrutiny to their work/organization than they would like. They may have local governmental contacts that provide coverage should there be any questions or problems. In these cases, the healthcare professional and the sending organization must assess the risk to both themselves and the host organization.  It is also important to factor into the equation relationships between the sender and receiving countries. Governments may express their displeasure by detaining or expelling missionaries, even medical mission teams to make a political point.   3.  A GOOD practice is to proceed with caution in countries where there is no stable government or health ministry/licensing organ.  Some team leaders would rather go without licenses, thinking that should there be a problem, they can plead ignorance and ask for forgiveness. This strategy is very risky and can lead to problems.   Consequences of not becoming licensed.   There can be significant amount of fall out for the people served, churches, participating local doctors, partners and governmental officials in-country.  For the people served, the exposure of the team’s lack of licensing may lead to concerns about the adequacy of their care. They may even wonder if their participation in such a situation may negatively impact them.  Churches can be negatively impacted by the perception of wrong-doing by short-term healthcare mission team.  For the participating local doctors, the disclosure that their short-term mission team partners have not followed the law, can create a perception of loss of reputation within the community.  Trust in the mission partner can be negatively impacted.   For partners, the disclosure that their short-term mission team partners have not followed the law can cause profound problems. From the government’s perspective, the partner is primarily responsible for the short-term mission team. Licensing for the partnership organization may be lost or even missionaries may be imprisoned or deported.   For the governmental officials, the disclosure that their short-term mission team has not followed the law, creates a question of who is responsible. If a mission partner is responsible, then prosecution of the mission partner is a possible route. If a governmental official is thought to be responsible, then they are at risk of losing credibility or even their position. For this reason, local governmental officials may be skittish about approving mission team visits. There can be a perception that there is more to lose than to gain unless the mission partner has a very strong relationship with the governmental official.   The major impact of problems related to no in-country licensing is a lack of trust that can destroy relationships. Works Cited BURTON, E. (2004, July 21). Dr. Montgomery released in Zimbabwe, charges dropped. Retrieved from The Zimbabwe Situation: http://www.zimbabwesituation.com/jul22_2004.html#link8 Hechel, H. &. (1979). Specialty certification in North America: a compartive analysis of examination results. Journal of Medical Education, 69-74. Johnson, D. A. (2005). Role of state medical boards in continuing medical education. Journal of Continuing Education in the Health Professions, 183-9. Mc Dougal, B. e. (October 2011). The 2011 Uniform Licensure Requirements for Adoption. Journal of Nursing Regulation, 10-22.      

Problem   Should short term missions projects be used as service learning opportunities for students in the healthcare professions?   As the world moves into a global society, increasingly there is a desire on the part of academic institutions to provide educational opportunities for students to experience what it means to be a global citizen.  Students are also seeking to have experiences in other countries.  For institutions and students involved in healthcare, this has included service learning opportunities in healthcare outside of the United States.  How these service learning programs are arranged and evaluated varies greatly.  At times the student initiates receiving academic credit for a short term healthcare missions trip.  More formal service learning programs will have dedicated faculty who are responsible to plan, implement, and evaluate the student experience.  The focus for service learning programs tends to be on the learning objectives for the healthcare student.  How the student service learning experience impacts the health or the healthcare delivery system of the people and healthcare systems of the host country is often not taken into consideration.    It has been noted that there are no guidelines for service learning programs for healthcare students. (Leffers, 2011)  There are guidelines for study abroad programs published by the Forum on Education Abroad and available at http://www.forumea.org/documents/ForumEA-StandardsGoodPractice2011-4thEdition.pdf and for short-term study abroad, http://www.forumea.org/documents/ForumEAStandardsShortTermProg.pdf.  Most of the guidelines focus on the US based educational institutions that are engaged in study abroad programming and are geared to guiding and protecting those institutions and students.  The guidelines are a good starting point for anyone interested in service learning programs abroad. (Forum on Education Abroad, 2014)   Within healthcare education, the topic of cultural competence increasingly is taking on importance as the United States becomes a more culturally diverse society.  Faculties are looking for global service learning opportunities for their students.  However, Cathleen M. Shultz notes that “most educators agree that service-learning is an experiential learning pedagogy that balances student and community needs (emphasis mine), uses reflective processes, and is directed toward aspects of student development; each element must be present.  Typically, volunteerism and nonreflective efforts which are offered by an increasing number of colleges and universities do not belong under the service learning umbrella.” (Shultz, 2011)   Recently, questions have been asked about the ethics of using short term missions for service learning experiences.  Matthew Decamp writes, “Ethical issues in medical outreach are often left to individuals’ professional guidelines.  We reject this approach for clinical trials in developing countries; we should also reject it for outreach.” (Decamp, 2007).  In the end, he acknowledges that there are differences between clinical trials and service learning programs but concludes “The comparison merely highlights our failure to consider the ethical issues of medical outreach.  What matters is that we can make progress on these issues, just as we did with clinical trials, and that progress is necessary for better global health work.  We are more likely to cause lasting harm when we fail to critically evaluate our actions.”   Research In 2011, the Nurses Christian Fellowship missions staff conducted a survey of Christian nursing schools who had global nursing education offerings.  (Jarlsberg, 2011)  Faculty members were asked about planning, leading, types of experience, language preparation, and partnerships related to service learning programs abroad.  94% of the 18 schools included in the survey indicated that they gave academic credit for experiences outside of the US.  50% of the faculty had some missions experience.  27% of the faculty indicated they had no international experience.  Only four faculty members were licensed in the country where the service learning program was conducted.  Experiences varied from observational and teaching to direct provision of care.  Two faculty members indicated that they were proficient in host country language and only one school required students to have a level II language proficiency.  Half of the schools had a partnership agreement.  Of them, four schools had partnership agreements with overseas academic institutions; seven schools had agreements with non-government or mission organizations.  Nine schools had no partnership agreements. The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) published some guidelines for ethics in global health training in 2010.  The guidelines were aimed at sending and host institutions, trainees, and sponsors.  The guidelines were derived from the experience of the working group members.  They noted that they had no data related to the potential benefits and harms on which to base the guidelines and encouraged further assessment and refinement of the guidelines based on data as it became available.  The WEIGHT guidelines “address the need for structured programs between partners; the importance of a comprehensive accounting for costs associated with programs; the goal of mutual and reciprocal benefit; the value of long-term partnership for mitigating some adverse consequences of short-term experiences; characteristics of suitable trainees; the need to have adequate mentorship and supervision for trainees; preparation of trainees; trainee attitudes and behavior; trainee safety; and characteristics of programs that merit support by sponsors.” (Crump, 2010)   Several articles have sought to look at the student outcomes in international service learning programs.  In 2010, Chavez, Bender, Hardie, and Gastaldo published an article on the lessons learned from a course evaluation of the Critical Perspectives in Global Health course.  Their findings comprised of the student’s sense of lack of preparedness with suggestions for more preparation prior to departure including what their role was to be and what they would be doing.  Students were assigned preceptors and some students thought that course instructors should have better evaluated the suitability of the preceptors.  Students also felt that upon return their reflection and debriefing could have had more structure and over a longer period of time for them to process the experience.  Some students questioned the benefit to the local community and what they had actually contributed to their welfare (emphasis mine). (Chavez, 2010)  One article compared an international service learning program with a service learning program in a local multicultural setting.  The authors found that students were able to achieve their learning objectives in either setting; but felt that the international setting provided the opportunity to experience a role in international collaboration. (Wros, 2010)   A recent systematic review of the literature, spanning 20 years January 1, 1993 – May 15, 2013, related to short-term medical service trips identified 67 articles that included data with the report.  These articles were then analyzed for common characteristics.  Of interest to short-term missions, the review found a decreasing number of publications reporting the work of faith-based organizations with only 18% of the publications identifying a faith connection.  The reason for this was unknown.  This could be because 1) the type of work done by faith-based organizations is not reported, 2) faith-based organizations do not include, collect or report data, or 3) faith-based organizations are not reporting their work in indexed journals. The author also questioned the current cultural discomfort with discussion of religion as a possible consideration.  The study found that most of the data focused on process outputs, I.e. numbers of surgeries, patient visits, etc.  The review questioned the ethics of just reporting outputs as opposed to reporting health outcomes.  The author suggested that the rigors of evidence based practice should be in place for short-term medical service trips as well.  The lack of outcomes also made it difficult to evaluate the cost-effectiveness of the medical service trips.  The study noted a lack of data to support claims of education in the area of cultural competency or career trajectory.  The study concluded that data collection and outcome assessment was necessary to evaluate the medical service trips.  Instruments designed for this purpose would be a first step in beginning this effort. (Sykes, 2014).    Within nursing education, faculties have looked to service learning programs abroad, to meet other learning objectives.  Johanson (Johanson, 2009) suggested that such experiences deepen nursing students’ commitment to service.  Others see this as an opportunity for nursing students to learn more about missionary and global nursing.  Wright has written articles that describe the planning process for a study abroad experience (Wright, 2010) and described the program she has developed. (Wright D. , 2011)  Similarly, Hawkins and Vialet, (Hawkins, 2012) describe a short-term missions experience from a student and a faculty perspective.   Solution   Ideally the following basics for service learning programs and/ or for short term missions programs which include student learning objectives would be in place: 1.    There would be a partnership between the sending institution/organization and the host institution/organization.  This partnership would: a.    Identify a project that would be mutually beneficial to the students engaged in the program and the recipients of their efforts. b.    Spell out the goals and objectives for the project. c.     Identify responsibilities of both sending and receiving institutions/organizations for the implementation of the project. d.    Include a plan for the evaluation of the project. e.    Include a budget for the project that clearly spells out who is responsible for the income and expenses related to each aspect of the project. 2.    A faculty member who is both familiar with the language and culture of the host country and hold professional healthcare credentials in the host country would oversee the project.  3.    Students participating in service learning programs would: a.    Receive adequate preparation in culture, language, and prerequisite professional knowledge before leaving for the service learning program, b.    Respect cultural mores of the host country and institution/organization. c.     Have access to professional supervision and instruction during the service learning project, d.    Have reflection assignments that would be part of the service learning experience, and e.    Debrief the experience upon completion of the service learning program. 4.    The service learning program would contribute in some measureable and documented way to improving the health outcomes of the host country. 5.    The service learning programs would follow legal and ethical standards in both the sending and receiving countries.   Recognizing that not many short-term missions programs or service learning programs are currently achieving this ideal, the guidelines should serve as a goal nonetheless.    Conclusion   As the next generation of healthcare professionals practice as global citizens in a global society, it is critical that their learning experiences model excellence in global health practice.  As Christian healthcare professionals we need to model ethical principles founded in a Biblical worldview.  We need to respect all people as created in God’s image.  That means that those we serve in limited resource countries receive care with dignity and respect afforded to people in our country.  It means that we also respect the laws and standards of care dictated by the governments and professional organizations present in host countries.  As Christ’s ambassadors, it means that we follow Jesus’ example of love and compassion toward those in need of physical and spiritual healing.  As participants in God’s Kingdom building activities, we seek to bring shalom, health and wholeness, to the people we serve wherever that may be.   Anything less than our best communicates disrespect and can potentially harm the health of the people we have gone to serve and discredit the gospel of Jesus Christ.  Short term missions projects can provide a base for service learning if both the sending organization and the receiving organizations in the host country assess, plan, implement and evaluate the project from both the student learning and the receiving community’s perspective.   Works Cited Chavez, F. B. (2010). Becoming a Global Citizen through Nursing Education: Lessons Learned in Developing Evaluation Tools. International Journal of Nursing Education Scholarship, 7(1), article 44,1-22. doi:  10.2202/1548-923X.1974 Crump, J. A. & Sugarman, J. (2010). Global Health Training: Ethics and Best Practice Guidelines for Training Experiences in Global Health. American Journal of Tropical Medicine and Hygiene, 83(6).1178-1182. doi: 10.4269/ajtmh.2010.10-0527 Decamp, M. (2007). Scrutinizing Global Short-Term Medical Outreach. Hastings Center Report 37(6), 21-23.  Retrieved from http://www.jstor.org/stable/4625794 on July 7, 2012.  Forum on Education Abroad. (2014, August 1). Forum on Education Abroad. Retrieved from Forum on Education Abroad: http://www.forumea.org/. Hawkins, J. E. (2012). Service-Learning Abroad: A life-Changing Experience for Nursing Students. Journal of Christian Nursing, 29(3), 173-177. doi: 10.1097/CNJ.0b013e31823fabf2 Jarlsberg, C. (2011). Global Nursing Education Survey. Madison, WI: Nurses Christian Fellowship. Johanson, L. S. (2009). Service-Learning: Deeping Students' Commitment to Serve. Journal of Christian Nursing, 26(2), 95-98. Leffers, J. &. (2011). Volunteering at Home and Abroad: The Essential Guide for Nurses. Indianapolis, IN: Sigma Theta Tau. Shultz, C. M. (2011). Global Service-Learning and Nursing Education. Nursing Education Perspectives, 32(2), 73. doi: http://dx.doi.org/10.5480/1536-32.2.73 Sykes, K. J. (2014). Short-Term Medical Service Trips: A systematic Review of the Evidence. American Journal of Public Health, 104(7), e38-348. doi:10.2105/AJPH.2014.301983 Wright, D. (2011). Service-Learning: Educatio with a Missions Focus. Journal of Christian Nursing, 28(4), 212-217. doi: 10.1097/CNJ.0b013e.31822b-4550 Wright, D. J. (2010). Planning a Study Abroad Clinical Experience. Journal of Nursing Education, 49(5), 280-286. doi: 10.3928/01484834-20100115-05 Wros, P. a. (2010). Comparing Learning Outcomes of International and Local Community Partnerships for Undergraduate Nursing Students. Journal of Community Health Nursing, 27, 216-225. doi: 10.1080/07370016.2010.515461