From UNC: “Nurses to Improve Training and Trust” A Great Story

U NC bloc

University of North Carolina

Bradley Allf

Undergraduates in the UNC School of Nursing Noemi Arias (left) and Stefanie Esteves Rosado (right) traveled to the Galápagos with Harlan in 2016.

On Jan. 1, 1933, a boy named Rolf was born in a cave on the island of Floreana, in an archipelago off the coast of Ecuador. He was the first child ever born in the Galápagos Islands. Rolf’s mother Margret Wittmer describes the experience in a book about her life as one of the first permanent settlers in the Galápagos.

“This time I screamed so loud that I started in terror at my own voice. It echoed back through the cave, loud and empty. There was no answering call. I lay quite still. There was a rustling at the entrance to the cave, an eerie rustling. It was still dark outside. An owl hooted. I heard a bull bellow, the bellowing came nearer and nearer, must be here by now, somewhere very near me… Then I heard a cry. It didn’t come from me…”

Rolf was born onto the wet cave floor that night without complications. But a day later, the placenta still had not been expelled. Wittmer’s husband sent for Friedrich Ritter, one of two other inhabitants on the island, who just happened to be a doctor. While Ritter was able to deliver the placenta—in return for a few sacks of pork— he had to do so without gloves, anesthesia or effective sanitation. Margret Wittmer was lucky not to have suffered a serious infection.

A lot has changed in the Galápagos since 1933. There are now 30,000 people living on the archipelago—now an Ecuadorian province—and the famous islands attract more than 200,000 tourists each year. There are schools, bars, airports and surfing competitions. On the four inhabited islands, day-to-day life is in many ways a far cry from the Crusoe-esque world inhabited by Wittmer.

But one thing that has changed comparatively little is healthcare. While babies are of course no longer being delivered in sea caves, the health infrastructure on the islands—largely made up of small, understaffed clinics— remains inadequate for the needs of the growing population. A new collaboration between the UNC School of Nursing, the UNC Center for Galápagos Studies, a hospital in the Galápagos, and the Ecuadorian university Universidad San Francisco de Quito (USFQ), is hoping to change that.

A sea lion pup on a beach in San Cristóbal. Wildlife in the Galápagos live in close proximity to humans, which poses some healthcare risks.
Photo by Bradley Allf

Sea Lions to C-Sections

The idea for this new collaboration came about through UNC’s “Galápagos Initiative,” a partnership between UNC and USFQ to foster research, education and outreach on the islands. Professor of Geography and Director for the UNC Center for Galápagos Studies Stephen Walsh, PhD, co-started the Initiative back in 2006.

Since then, the Initiative has accomplished a lot, including the construction of a brand-new 20,000 square-foot research facility on San Cristóbal Island called the Galápagos Science Center. This center, complete with full research laboratories and modern scientific equipment, hosts scientists from all over the world that are trying to better understand the Galápagos. Many of these researchers are interested in what researchers have traditionally been interested in on the islands: the biology of the iguanas, finches, sea lions and other wildlife that call the archipelago home.

But the Initiative reaches far beyond just ecology and evolution. It also aims to better understand the human dimensions in the Galápagos, and how UNC and USFQ can work within the island communities to engage with the populations’ needs. Prominent among these needs is healthcare. And that’s where the UNC School of Nursing fits in.

“Over time it was certainly impressed upon us that the Galápagos is in need of enhancements in healthcare and medicine,” says Walsh. “And part of the reason is a long-term legacy of ineffective healthcare.”

That legacy can be traced all the way from Rolf Wittmer’s birth in a cave to now. Modern-day births on Isabela Island, for instance, take place in a clinic without fetal monitoring capabilities save one outdated ultrasound machine.

So Walsh, along with the Dean of Public Health at USFQ Jaime Ocampo, MD, PhD, MBA, and UNC Professor of Nutrition and member of the UNC-USFQ Advisory Board for the Galápagos Science Center Peggy Bentley, PhD, started putting together a series of tactics for addressing the healthcare needs. Chief among these was bringing the School of Nursing on board.

“It was clear to me that we would benefit from collaborating with the School of Nursing.” says Walsh. “And so I reached out to Gwen Sherwood about the advantages of getting them involved in Galápagos.”

Gwen Sherwood, PhD, RN, FAAN, ANEF, is the associate dean for Practice and Global Initiatives in the UNC School of Nursing. Sherwood says she jumped at the opportunity to continue the School’s long legacy of international collaboration. With the administrative support and encouragement of then Interim Dean of the School Donna Havens, PhD, RN, FAAN, at her back, Sherwood began meeting with Walsh and the other partners to learn how her department could help.

This delegation decided that Sherwood, accompanied by Bentley, should head down to the Galápagos to get a better idea of how the School of Nursing could use its resources to improve healthcare on the islands.

A marine iguana sitting on a beach in San Cristóbal. Photo by Bradley Allf

The Role of the Environment

In February of 2016, Sherwood boarded a plane headed to the Galápagos Islands. One of the first things that struck her upon arriving was how the human and natural worlds co-mingle.

“You’re sitting having breakfast on a deck and the iguanas are right here and the sea lions are sitting in the chair next to you and they don’t even know to react. It’s amazing,” says Sherwood.

But these same aspects of life that make the Galápagos so unique also create unique challenges for health. Those same friendly sea lions also defecate all over the island’s public beaches and boardwalks, presenting opportunities for the spread of disease. The bright equatorial sun, while pleasant on the beach, puts Galapagueños at increased risk for skin cancer. Water is often poorly filtered and almost all food must be imported from the mainland, driving up the cost of healthy perishables like fruits and vegetables.

Seeing all these issues for herself showed Sherwood what a significant impact well-trained nurses with adequate resources could have as the health interface between the public and their surroundings.

“In nursing, we think about nurses as having a major role in helping people with the how they interact with the environment. Especially when we are working with people in community health settings, the social and environmental determinants of health play a major role in how people manage their health,” says Sherwood.

So what can the School of Nursing do to improve this health interface? Sherwood decided, based on her firsthand experience in Galápagos, that the best way for the School to begin to get involved would be to start an ongoing professional development program for nurses in the Galápagos. Upon returning to Chapel Hill, she got in touch with another nurse at UNC with the skillset to begin implementing such a project.

Chris Harlan, RN, MA, in a blue shirt and red capris (it was the 4th of July!) standing with nurses from Hospital Oskar Jandl on San Cristóbal, Galápagos.

A Hospital in the Shape of a Turtle

That nurse was Chris Harlan. Harlan, RN, MA, is a clinical assistant professor in the School of Nursing. Harlan is fluent in Spanish, was a member of the Peace Corps, and has lived in Central and Latin America. She also has an anthropology background. Sherwood says she was the “ideal faculty member” for the collaboration.

Harlan happily agreed to go to San Cristóbal to learn more about what nurses on the island would like to see in a professional development series. Specifically, Harlan would work with the nurses in the newly constructed medical facility on San Cristóbal, “Hospital Oskar Jandl”—built in the shape of a turtle, of course.

Harlan brought with her two nursing students who were interested in getting involved in the project, and who were also native Spanish speakers. The main goal for this group was to interview the nurses at Hospital Oskar Jandl to see what they were looking for in a professional development series.

One of the most common requests was for learning quality improvement strategies, specifically in maternal-child quality and safety developments. This is something UNC has been working to address in its own hospitals, so Harlan thought it could be a good starting point for creating a relevant professional development program going forward.

While on the islands, the team also assisted Bentley with interviewing locals about their attitudes and perceptions regarding the new hospital. This aspect of the trip was particularly important because despite the hospital being, as Harlan puts it, “a huge improvement over what the island has had for forever,” few people seemed to be using it.

“There is a big problem between the community and the hospital on San Cristóbal and that problem is called trust,” says Jaime Ocampo, dean of public health at USFQ. Ocampo states that, because of the legacy of poor healthcare on the islands, most people that can afford to travel seek their healthcare on the mainland.

Beyond the legacy of ineffective care, this mistrust is fueled by the transience of healthcare workers in the Galápagos. By law, only native-born Galapagueños can live on the islands permanently. Thus, healthcare workers from the continent can only stay on the islands for a year or two. This obviously complicates continuity of care, and helps contribute to the local perception of these doctors and nurses as outsiders.

But taking an airplane all the way to Quito or Guayaquil just to go to the doctor requires a lot of time and money. And relying solely on mainland doctors can be dangerous in emergencies, as it can take hours to get a plane to the mainland.

Harlan hopes that the collaboration between Hospital Oskar Jandl and the UNC School of Nursing will lead to better training for the nurses, which will increase public trust in the hospital over time.

There are, of course, myriad physical resources the nurses would like to have in the hospital, including a blood bank and an intensive care unit. However, at this stage the School of Nursing is keeping its focus on developing a highly effective professional development program.

“The short-term vision is that we will develop a team of folks who will be able to travel once or twice a year to provide workshops or educational programs for the staff there,” says Harlan.

Still Early Days

Broadly speaking, Ocampo sees UNC’s involvement with improving healthcare in the Galápagos as having three main aspects: research, training and medical assistance. The School of Nursing will figure prominently into all three of these aspects.

As the collaboration is still very much in its infancy, the research aspect is currently most central to the project. It answers the question: what is the need? The UNC nurses involved in the project will continue working with hospital staff to understand this need, and how the School of Nursing can most effectively address it.

The second aspect of the School’s involvement on the Galápagos is training. How can the School of Nursing work with the Galápagos nurses to better equip them to provide healthcare? Harlan, Sherwood, and the others involved in the project are excited to implement their professional development series to begin addressing this goal.

The third aspect, medical assistance, will eventually involve a nurse exchange program whereby nurses from UNC can stay in Galápagos for extended periods, and vice-versa. However, at this stage such a program is still a long way off.

Collaborative, Community-Focused Care

While making these plans, however, Sherwood stresses how important it is to ensure that this project is not ham-fisted in its approach—that it’s a collaboration with USFQ and the Galápagos healthcare workers in the truest sense of the word.

“It’s not ‘go and do,’ it’s ‘how can we form teams,’” says Sherwood. “In nursing, we often rush into intervention and we rush to acute care whereas sometimes it would be helpful for us to step back and look at the community where populations reside and try to take time to understand what is behind the presentation of the illness. What’s the story that we could better understand in terms of how we coordinate health here?”

Understanding that story starts with understanding the community, and that’s something central to the entire Galápagos Initiative.

“Early on [in the Initiative], not only did we create a scientific advisory board made up of faculty from UNC and USFQ,” says Walsh. “We also created a community advisory board made up of local people—shop owners, restaurant owners— people that care about the question ‘what are you doing for us?’”

The Galápagos Initiative team is even developing a community research symposium, where they plan to explain to the public every single project they’re involved in and how each one benefits those living on the island.

Going forward, the School of Nursing wants to keep this sort of community focus at the center of their involvement on the islands. Additionally, Harlan and Sherwood are working to continue expanding the project’s intradepartmental breadth. For example, they have invited the new Dean of the School of Nursing Nilda Peragallo Montano, DrPH, RN, FAAN, to visit the islands this summer to learn more about the collaboration.

It’s important to understand that the School of Nursing is by no means the only group in the Galápagos Initiative working to address the healthcare problems in the Galápagos. There are many other departments at UNC and USFQ working alongside the School of Nursing to bring better healthcare to the islands.

With any luck, this collaborative approach will help facilitate a healthcare transformation on the islands to better meet the healthcare needs necessitated by such a unique place.

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