UCSF and Partners in Health Collaborate to Make Sustainable Change in Haiti

September 2014Diana Austin

When a 7.0-magnitude earthquake struck Haiti in 2010, the small island nation’s health system was already in crisis. Haiti was already at or near the bottom of its region on leading health indicators such as child and maternal mortality, HIV prevalence and immunization rates; the cholera epidemic that erupted in the months following the quake strained Haiti’s health care infrastructure to the breaking point.

A new collaboration between the UCSF schools of nursing and medicine and Partners in Health (PIH), a nonprofit organization that brings medical care to those most in need, aims to strengthen Haiti’s health care system by increasing the expertise of trained health care providers in Haiti and empowering them to enhance the delivery of patient-centered care within interdisciplinary teams.

Challenges to Creating Sustainable Infrastructure

One of PIH’s goals is to work within an existing system to create sustainable infrastructure. That’s difficult, says Sheila Davis, PIH’s chief nursing officer, because many global health projects bypass existing systems rather than working to strengthen them. “It can be easier to build your own hospital,” she says, “but it’s often not integrated into existing health systems, which is a missed opportunity to build infrastructure.”

Haiti is a prime example. According to Davis, an estimated $6 billion in outside aid was funneled to Haiti after the earthquake, but less than 10 percent went to the Haitian government, and only 1.4 percent went to Haitian companies and organizations. The rest remained with US, Canadian or other organizations outside Haiti to distribute aid. Any effort at improving health care that attempts to lay an outside system over what already exists will not be sustainable, says Davis.

The UCSF-PIH collaboration is a three-part pilot project, funded by a two-year grant from an anonymous PIH board member who has worked with UCSF’s schools of nursing and medicine on several other projects.

A Residency Model for Global Health Nursing

The project will begin at Hinche Hospital in Haiti’s Central Plateau and potentially spread to other hospitals and regions in the country.

Part one – the Global Health Nurse Fellowship Program – will send two UCSF graduate nurses to complete six months of a yearlong residency, split into two three-month periods, at Hinche Hospital. For the remaining six months of the residency, they will work with UCSF faculty, teaching and assuming clinical duties in the School of Nursing’s Family Nurse Practitioner Program.

Evan Brown (left), Brooke Finkmoore Modeled on the ongoing UCSF Global Health-Hospital Medicine Fellowship, the Global Health Nurse Fellowship Program is among the world’s few yearlong residency programs in global health open to nurses. This year’s fellows, Evan Brown and Brooke Finkmoore, both 2014 nurse practitioner program graduates, recently began training to prepare them for the complexities of working in a low-resource setting before heading to Hinche in early October to begin their residency.

Finkmoore and Brown each developed a passion for global health and working in low-resource environments early in their careers. Before going into nursing, Brown was a volunteer and an intern for HOPE worldwide, an international organization that provides community, health and social services to the world’s poorest citizens. Finkmoore, who also holds a master’s in public health, was motivated to pursue a nursing career after working in Mozambique as a Peace Corps volunteer and conducting public health research in the Northeast of Brazil. When the opportunity arose to apply for the Global Health Nurse Fellowship Program, both jumped at the chance and were delighted to learn they had been selected.

“I was over the moon,” says Finkmoore, who says her experiences working internationally showed her how integral well-trained nurses are to the delivery of high-quality health care. She’s especially happy to be returning to Haiti, where she has previously volunteered as a nurse working with HIV and TB patients. “I was really taken with the vibrancy of Haiti and the spirit and the dedication, and I knew I wanted to get more experience and to be a part of big projects and long-lasting, systems-level change…things that will really shape the future of health care delivery in Haiti.”

Empowering Nurses to Provide Patient-Centered Care

Ellen Scarr, health sciences clinical professor and lead faculty for the Global Health Nurse Fellowship Program, first forwarded the idea of a global health residency for nurses after conducting an on-the-ground needs assessment in Haiti.

“I was struck by how eager the nurses were for more education. They’re starting at a basic level,” she says. As advanced practice nurses, Brown and Finkmoore are well versed in clinical decisionmaking and developing care plans – skills they hope to be able to pass on to their Haitian colleagues. They’ll work with nurses in Hinche to develop learning opportunities to help improve care and expand nursing knowledge. Equally importantly, says Scarr, they will serve as role models and mentors for nurses working the medical and pediatric wards. This role-modeling is integrated into the second part of the collaboration, the Patient- and Family-Centered Rounding (PFCR) Project.

This project is based on interprofessional teamwork models at UCSF and will partner experienced faculty from UCSF schools of nursing and medicine with Haitian nurses and physicians to develop and implement an interprofessional rounding model to bring patients and families into the health care team and to improve communication among all team members. PFCR encourages team rounding at the patient’s bedside and a technique known as “closed-loop” communication, which involves repetition and acknowledgement to reduce misunderstandings.

Team rounding at the patient’s bedside can be especially valuable in hierarchical health care environments like Haiti’s. The needs assessment revealed that nurses in Haiti don’t feel empowered to advocate for their patients, says Scarr. Studies have shown that PFCR can improve team communication between physicians and nurses, increase patient satisfaction and improve patient outcomes.

“Nurses [in Haiti] would like to be able to participate in rounds and advocate for the patient, and our graduates and faculty can help model how to do that effectively,” says Sally Rankin, professor emerita and associate dean for Global Health and International Programs in the School of Nursing, who helped develop the program.

As recent School of Nursing grads, Brown and Finkmoore have studied and worked alongside physicians, pharmacists and other clinicians since the start of training and are comfortable with the nurse’s role in interprofessional teams. Finkmoore cites her experience working alongside second-year internal medical residents in the UCSF/VA Medical Center EdPACT (Education in Patient Aligned Care Teams) program as an example.

“You participate in a variety of didactic courses about working together, about panel management, about best patient care, and each learns what skills the other brings to the table. I think that kind of interprofessional collaboration will be a huge skill I bring with me [to Haiti],” she says.

Empowering nurses in this way is about more than just job satisfaction. Research suggests that nurses who feel empowered experience higher job satisfaction and are less likely to leave the profession – a crucial consideration for increasing capacity in a country with only 1.1 nurses and midwives per 10,000 individuals, the lowest ratio in the region.

Creating a New Generation of Nurse Leaders in Haiti

In the third component of the collaboration, the Faculty Development Certificate Program (FDCP), up to six Haitian nurses and physicians will participate in a yearlong curriculum, including a two-week intensive at UCSF, with ongoing mentorship from senior UCSF faculty. The goal is to develop teaching, leadership and mentorship skills. Graduates will subsequently train and mentor their colleagues as they complete the program.

Training Clinicians to Work Together for Sustainable Change

The benefits of the collaboration go both ways. The US-based nurse and physician fellows will hone their leadership and mentorship skills alongside their Haitian colleagues and get real-world experience working for change within a challenging health care system.

That’s especially valuable for the increasing number of clinicians interested in global health, says Davis. “Lots of projects are driven by well-meaning people who don’t know much about health or about the system they’re working in,” she says. Projects like the UCSF-PIH collaboration avoid that trap by ensuring that the expertise and enthusiasm of nurses and physicians interested in global health are firmly harnessed to the knowledge of local clinicians working to make sustainable change in their country’s health.