Filling In The Gaps

Africa has had a hold on Jane Blood-Siegfried, PhD, RN, CPNP, ever since she was a girl, when she lived in Liberia with her family and, among other things, cared for a succession of orphaned baby chimpanzees, one of whom slept in a crib in her room and occasionally clambered up onto her bed and plucked the rollers out of her hair. Her family left Liberia, where her father had been stationed as a U.S. State Department official building schools, when she was 15. Decades passed before she was able to return, but Blood-Siegfried never forgot the vivid experience of living in Africa, a vast continent brimming with both spectacular beauty and heart-wrenching suffering.

Now she and Duke University School of Nursing are launching a project designed to help ease some of that suffering by bringing improved primary health care to people in one part of Africa. In close collaboration with multiple partners in Tanzania, Blood-Siegfried and the School of Nursing have begun a five-year plan to establish a program that will develop and train Family Nurse Practitioners (FNP) to serve rural communities there. Like much of sub-Saharan Africa, Tanzania suffers from severe shortages of health care personnel and resources. Physicians are virtually non-existent in most rural areas. Nurses serve as the backbone of the health care system outside the cities, but there are not enough of them, and those that are in practice seldom have sufficient education to provide the full range of comprehensive care.

“The heavily populated areas of Tanzania have fairly good health care, but 70 percent of the population lives in rural areas, and out there the situation is not as good,” says Blood-Siegfried, who has been at the School of Nursing for almost 20 years. “Usually there is somebody who provides health care, but in most cases they are not trained or qualified to do the procedures they have to do. So you have lab technicians delivering babies, suturing wounds, and basically providing primary health care, simply because there’s nobody else there to do it. If there’s a registered nurse on site, that’s a step up, but even the nurses aren’t trained to do the types of things a nurse practitioner would do.”

Her program is intended to put more qualified practitioners into those rural areas. She and other School of Nursing faculty will work with their counterparts at the Kilimanjaro Christian Medical University College Department of Nursing (KCMU-Co) to prepare a curriculum, develop Tanzanian faculty, and begin training the first cohorts of FNPs. The program will prepare its graduates to provide and manage the primary care health challenges of rural communities. “There are only two other Nurse Practitioner (NP) programs in all of Africa: one in Ghana, and one in Botswana,” Blood-Siegfried says. “So this is a pretty big deal. It has the potential to help a whole lot of people.”

VALIDATING ROLES

Blood-Siegfried organized a four-day conference, which was held in Arusha, Tanzania, in February of 2015 to bring together all of the project’s partners and stakeholders—the universities, the Tanzania Nursing and Midwifery Council, the Tanzanian Nurses Association, and Ministry of Health—along with representatives from the NP programs in Ghana and Botswana to offer their guidance and advice. That gathering produced consensus about the program’s goals and a detailed action plan to guide its progress.

Next steps include developing the curriculum, based on a needs assessment that was completed last fall, and preparing the initial faculty—two post-baccalaureate nurses who will attend FNP programs in Botswana or Ghana and then return to KCMU-Co to teach the first cadre of FNP students. That first class of students, and probably several subsequent classes, will consist of experienced registered nurses already providing health care in rural areas. If all goes according to plan, within five years the initial cohorts of FNPs will be returning to the communities they serve, with more knowledge, more training, and more authority to provide the necessary care to their patients.

“Jane’s program isn’t so much introducing a new role as it is validating a role,” says Michael Relf, PhD, RN, ACNSBC, AACRN, CNE, FAAN, associate dean for global and community affairs. “The nurses are there. They are performing at a high level. What we want to do is train them further, standardize theirskill sets, and formally validate their competencies, so that when they return to their communities they’ll be trained and qualified to do the things they have to do.”

Faculty from the School of Nursing will help teach intensive classes in the new program, at least during its formative years, and Duke students will have opportunities to go to Tanzania and participate by shadowing FNPs, doing hands-on work in clinics, and other activities. Relf said he hopes Tanzanianstudents will be able to come to Duke to gain the same sort of experiences.

A $200,000 grant from the Mark Paul Terk Charitable Trust is funding the initial phases of the project, and partners at Duke and in Tanzania are seeking additional funding.

Relf and Blood-Siegfried hope the Tanzanian FNP program can piggyback to some extent on the successful medical education program that John A. Bartlett, MD, HS’81-’84, ‘85-’87, professor of medicine and global health and associate director of the Duke Global Health Institute, has established at Kilimanjaro Christian Medical Center. “The potential is there to work collaboratively with John Bartlett’s group so that our students can learn with the medical students as well as use some of the facilities for unique learning,” says Relf. “Sometimes the question isn’t ‘How do we build something?’ but ‘What resources are already there that we can share?’”

SIMILARITIES AND DIFFERENCES

Duke University School of Nursing has a renowned nurse practitioner program in Durham. Launching a similar program in Tanzania is a far more complicated matter than simply lifting what the school does here and dropping it over there. The conditions, facilities, health problems, treatment protocols, and cultural norms are very different in the two places.

“Ears look the same everywhere. Hearts sound the same,” says Blood-Siegfried. “But the needs of the community in Tanzania are very different from the needs here. We’re not trying to bring an American nurse practitioner program to Africa. We’ll be tweaking it for the needs of Tanzania.”

Here, for example, nurses and nurse practitioners learn and perform a lot of geriatric care, because the U.S. has a large elderly population. In Tanzania, average overall life expectancy is under 60. So training and practice place a relatively smaller emphasis on elder care. 

Nurses in the U.S. tend not to spend a great deal of time studying and treating tropical diseases such as malaria; in Tanzania, they do. Even conditions that are common in both places— hypertension, for instance—are treated with different formularies in the two countries.

Health care practitioners in rural Tanzania don’t have access to very much in the way of high-tech diagnostic and treatment equipment. “You don’t send somebody for an MRI, because you aren’t going to find one,” says Blood-Siegfried. “It’s an amazing challenge for U.S.-trained people, because in a lot of ways you have to learn to diagnose and treat people the way the old-time family doctor used to. They use the history and physical findings to make a diagnosis. You can look at someone and tell whether they’re anemic, for example. In Tanzania, in a lot of places, you’re not going to be able to look to a blood test or other tech-driven diagnostic tools.”

In some cases, she says, the cultural differences can be difficult for practitioners from the U.S. to accept. “We have some students who go to Tanzania to work in clinics, and it’s wonderful; they learn a lot,” says Blood-Siegfried. “But it’s a challenge, too, because they have to adapt to a different culture’s way of doing things. In Tanzania, when a woman has a baby, the woman gets looked after first and the baby gets looked after second. Because if a baby dies, the mother can have more children. But if a mother dies, that affects the whole family forever. That kind of culturally specific way of looking at things can be a real adjustment.”

KNOWLEDGE AND SERVICE

The Tanzanian Family Nurse Practitioner program is just the latest of several School of Nursing initiatives in Africa. Brett Morgan, DNP, CRNA, has established a Duke Global Health Bass Connections program to train nurse anesthetists in Ghana. (Morgan, Blood-Siegfried, and Jennie De Gagne, PhD,DNP’14, RN-BC, CNE, recently received appointments as adjunct professors in the University for Development Studies School and Medicine and Health Science Department of Anesthesia in Ghana to support that project.)

The School of Nursing and the School of Medicine both are active in the Rwanda Human Resources for Health program, a seven-year, 13-school project to build a sustainable health care system there. And Robin Dail, PhD, RN, FAAN, is in the first stages of a project to help prevent infant hypothermia, also in Rwanda.

All of these projects support the university and health system-wide Duke Africa Initiative, launched in 2012 to build connections and share knowledge among Duke scholars who have a shared interest in Africa. “One of the things we’ve tried to do is strategically align ourselves with broader Duke initiatives,” says Relf. “It all goes back to Duke’s mission of knowledge and service to the world. All of these programs are an opportunity for our school, our faculty, and our students, in partnership with collaborators overseas, to bring knowledge and service to the world.”

The key word is “partnership,” Relf says. He receives calls and e-mails every month from representatives in nations throughout the world asking Duke University School of Nursing to help them build nursing schools in their countries. “Well, that’s not really what we do,” Relf says. “We don’t have the capacity to start schools of nursing. But what we have decided as a guiding principle is that when there are mutually beneficial partnerships, then we will engage in that activity. Jane’s work is an example of a mutually beneficial partnership. Tanzania has a need. We have capacity. We’re going to leverage mutual resources to develop a relationship that will help them meet their need and expand our capacity through research, scholarship, student clinical experiences, and so on.”

One of the keys to success, he says, is humility.

“None of this works if we were to go in there with the attitude that, ‘Here we are, Duke University in America, and we’re here to save you,’” he says. “We are very, very sensitive that we are equal global partners with the people in our host countries. We have as much to learn from them as they do from us. When we treat everybody as peers, as equal partners, then we’re really meeting that mission of knowledge and service to the world.”

Ideally, Blood-Siegfried says, the Tanzanian FNP program will ultimately lead to improved care for rural residents and will become a self-sustaining, long-term program that will continue to benefit the country and its people for years to come. There are a lot of steps to take before that day comes.“There are still a thousand questions,” says Blood-Siegfried. “But we’re under way. A few years ago I went back to Africa. I saw that there is definitely a need, but I also realized that there’s a lot to learn. We’re letting our partners in Tanzania determine the needs and the curriculum. We’re there to help, tofacilitate, and to fill in the gaps.”

(The article is written by Dave Hart and was originally featured in the Summer 2015 Duke Nursing Magazine)
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