Rezime : Atik sa a dekri devastasyon ki genyen nan pwogram etid enfimyè nan peyi Ayiti ak konsekans sa genyen sou sektè lasante piblik. Pou ogmante nivo fòmasyon enfimyè yo Asosiasyon Enfimyè Ayisyano-Ameriken prezante yon pwojè pou sipòte yon lekòl enfimyè nan Leyogàn

1. NATURE OF THE PROBLEM1

It is a well known mantra that Haiti’s health care system is in crisis ; many even use the terminology that Haiti’s health care system is on life support. A 2003 Red Cross study [1] indicates that there is less than one hospital bed per every 1000 patients throughout Haiti and, according to Tarabula,[2] two hundred nine (209) surgical beds for the six million people living outside of Port-au-Prince. Only about 60% of Haiti’s 9 million residents have access to any form of health care services, according to the Pan American Health Organization (PAHO).[3] Furthermore, most people rely on public facilities where they must pay a minimal fee based on income and family size. Alarming statistics on Haiti’s life expectancy and mortality report the average life expectancy at birth to be 50 years and the infant mortality rate 79 per 1000 live births [4]. The mortality rate among children under 5 is 123 per 1000 live births. A Health care system, in its working definition, is almost nonexistent in Haiti. The World Health Organization (WHO) defined health in its broader sense in 1946 as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Health is not just a state, but also “a resource for everyday life, not the objective of living. A number of other factors are known to influence the health status of individuals, including their background, lifestyle, and economic and social conditions ; these are referred to as “determinants of health” (Wikipedia, 2012) [5].

1. Chair of Education for the Haitian American Nurses Association of Florida (HANA)

As such, access to primary health care for all is the basis for any public health care system. Published health indicators before the January 2010 earthquake, both by the Ministry of public health and population (MSPP) and by the United Nations program for development (UNDP), already revealed an undeniably worrying state of the premises [6]. Several major deficiencies have been and are still unanimously identified in the Haitian system. The most frequently cited are : 1) the imbalance in geographical distribution of institutions and providers of health, 2) under funding by the State which provides less than one-third of expenditures in health, 3) deficient training for graduates and without a program of maintenance of competence in the public system, 4) the exodus of the graduates, 5) rates of infant mortality (8.6%) and kindergarten (6.3%) which are among the highest in the Americas, and 6) the paradox of humanitarian assistance in health. (CMAJ April 27, 2004 vol. 170 no. 9 doi : 10.1503/cmaj.1040541) [7] To address one of the aforementioned deficiencies, the Haitian American Nurses Association of Florida, Inc (HANA) has undertaken an initiative to partner with selected nursing schools in Haiti and steadily provide them with educators from the Diaspora to bridge the gap in the lack of nursing educators in Haiti. HANA has identified this area where resources from the Diaspora can make a lasting and sustainable impact. From our research we have discovered the following : 1) Haiti does not offer a supply of qualified nursing and health care educators to teach the next generation of professionals and too often, schools are unable to find qualified teachers — a phenomenon that results in dire consequences on Haiti’s health care system. 2) The schools lack basic resources such as materials and equipments, which can impede learning

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and demonstration of basic nursing skills. 3) Many classrooms in the nursing schools lack basic infrastructure such as adequate ventilation and air-conditioning or an environment not conducive to learning. The administration, faculty and students are acutely aware of these deficits facing their education system. After witnessing the absent or at best paralyzed response of the Haitian nurses of Haiti after the devastating aftermath of the earthquake of January 2010, HANA decided to establish a long term collaboration with the Faculte des Sciences Infirmieres de Leogane (FSIL) at the Episcopal University of Haiti to support its curriculum by helping in educating the future generation of nurses. With HANA’s support, the graduates will be better prepared in academics and practical skills, and fully able to meet the needs of the community upon graduation. FSIL is a nursing school located 20 miles west of Port-auPrince, in the town of Leogane. It is the first baccalaureate degree nursing program in Haiti. The nursing school was started in 2005 to help improve the care at Hopital St. Croix (HSC) located in Leogane, Haiti. HANA has developed an education initiative with the nursing school of Leogane (FSIL) to address the inadequacy of nursing education and to enhance the quality of care by providing nursing students with an opportunity to incorporate nursing skills with actual patient care.

2. Goals of the initiative are to : • Produce an informed cadre of future nursing leaders ; Haitian-American educators will introduce Haitian nurses to a higher level of professional and skilled education; • Introduce students to interdisciplinary learning and delivery of care through experiential, interactive and didactic learning methods;

5) Training nursing students and faculty members to become community health agents and to maintain health care services to the population ; and lastly 6) Establishing a solid health care system in Leogane to educate and provide direct health care services to the population. HANA has been sending at least one nursing educator per month to Leogane to teach and transform students into global nurse leaders by exposing them with current practical and technological knowledge. The educators teach subjects such as Health Assessment, Pediatric Nursing, OB/GYN Nursing, Community Nursing, Public Health, Mental Health and Leadership. HANA’s volunteer educators develop programs that give the Haitian nursing students more opportunities to broaden their knowledge and provide hands on training using latest technology and modern equipments with a culturally and linguistically sensitive approach. The teaching program aims to involve clinical training in the community and hospital settings in Haiti and also offer opportunity of hospital immersion in the United States.

3. EXPECTED OUTCOMES OF THE PROJECT The nursing school initiative is instrumental in the training of professionally prepared future Haitian nurse leaders. With proper guidance and the acquisition of skills and knowledge, the nurses will become leading nurse practitioners and educators, as well as advocates for quality nursing care in their community. Educating these future community leaders while they are in training will help the students to fully understand the need for quality health care for their community. The nursing school initiative will accomplish the following : • Expose nursing students to scientific based curriculum; • Enhance and redefine nursing skills;

• Introduce customer service skills and enhance assessment skills to the graduates;

• Improve assessment skills to render prompt treatment to clients;

• Enhancing understanding of scientific theories, provide and assist with obtaining durable modernize medical equipments to the nursing school;

• Improve understanding of symptom management and preventive home care;

• Teach nursing students how to utilize donated equipments to improve and provide fast and efficient care. HANA’s initiative seeks to improve nursing education by : 1) Addressing the current shortage of qualified nursing instructors ; 2) Providing nursing students experiential learning opportunities to acquire skills and knowledge in nursing care ; 3) Enhancing global nursing knowledge in order for Haitian nurses to become strong advocates for their clients and their community ; 4) Introducing and disseminating resource materials to nursing students via website and online classes ;

• Provide knowledge on the importance of community-based nursing; • Improve Recognition and response to emergency medical care; • Design and develop a plan that will maintain and improve standard of care in their communities. Another facet of our involvement in FSIL is the financial backing of a Disaster Preparedness project in order to ready the school and its surrounding community in case of another disaster.

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The purpose of this Disaster Preparedness Project is to establish sustainable non-government policies and procedures for disasters at FSIL, through Worldwide Community First Responder, Inc. This is accomplished by : • assessing the FSIL community’s risk and vulnerability for disasters; • planning a community-based first response and first aid training program; • training FSIL students in community-based first response and first aid; • developing a FSIL Disaster Preparedness Plan. As in the Haiti earthquake of 2010, the succession of events in an emergency are not predictable. Residents in the geographical location of FSIL may be affected ; therefore emergency services may not be available. Depending on the scale and intensity of damage, the community could be left stranded for up to seventy-two hours until external assistance reaches them (World Health Organization, 2007) [8]. Following any disaster, the first seventy-two hours are most crucial (International Federation of Red Cross and Red Crescent Societies, 2010). [9] FSIL may be the only institution who could help the community. The damaging effect of a disaster can be considerably reduced by well-trained FSIL students, who can be self-sufficient within 72 hours following a disaster. A good training program can make all the difference. The FSIL Disaster Preparedness project will engage FSIL students in making the FSIL community safer, more prepared, and more resilient. The goals of this project were delineated to : • establish capabilities for protecting FSIL community from the most devastating effects of a disaster; • respond effectively to the actual occurrence of a disaster at FSIL; • provide first aid in the aftermath of a disaster within the FSIL community; • plan and maintain an updated disaster preparedness Plan at all times at FSIL.

or able to leave their family and responsibilities in the states to go spend a full week or more in Haiti. 2. Lack of nurse role models in Haiti : It was surprising to find novice nursing students being left on their own with patients and not an employee nurse in site. The student is left to find her own way and no one to model nursing care and skills. This phenomenon was explained as being due to the fact that hospital employees can go months without receiving a salary. 3. Lack of ethics and dignity in the workplace : Very evident in the hospitals and health care communities were lack of respect, compassion and caring attitudes toward the patients ; instead, what could be seen was a sense that I’m better than you or I don’t have time to waste on you, rather than being a servant to care for the sick and the less fortunate. This attitude can be best explained by a lack of knowledge and training regarding the importance of caring for the person as a human being who deserves to be cared for with dignity and respect regardless of his socio-economic acumens 4. Disregard for the health institutions’ neutrality and immunity : Historically, during periods of unrest in Haiti, several hospitals have been the target of violence. Patients have been assaulted in some institutions and the staff providing care is worried about exercising their duties safely resulting in staff not reporting for work on days of demonstrations. Some patients in need of emergency care cannot reach a hospital for fear of meeting with violence. The main hospital in Port-au-Prince has known periods of standstill for weeks, for lack of personnel. 5. Supply difficulties in health institutions : It is increasingly difficult to supply hospitals with drugs, medical surgical consumables, water, propane gas, and diesel. Stocks of drugs are not renewed in peripheral warehouses located in zones of difficult access. As a result, emergency care and other essential services are not guaranteed.

Though the initiative has been well received and spreading to other nursing schools in the area, we also met some challenges. Some of the challenges are not solely unique to nursing education in Haiti ; rather they are part of the dysfunctional fabric that constitutes Haiti’s health care system.

6. Precariousness of the access to care : As cited in countless studies, access to well-equipped health care facilities remains a major challenge for patients and care-givers, due in part to limited accessible facilities, inefficient road system, and the overall economic situation.

1. In the United States, HANA encountered the surprising and unexpected road block of the scarcity of Haitian-American nurses to volunteer to travel to Haiti. Although HANA underwrites the entire trip including providing stipend for the volunteer nurse educator, we found it very difficult to recruit qualified nurses willing

7. Lack of precise information : Maintenance of proper documentation is almost non-existent. The health effects of the crisis are not documented properly due to a failing routine health information system. This lack of information sharing and keeping is a major obstacle to proper continuity of patient care.

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8. Fragmented health care delivery : Many goodwill organizations are bridging the gap in the Haiti health care crisis ; however, it all feels like a Band-Aid solution because of the fragmented pattern of delivery. Though, many foreign organizations including the Haitian Diaspora, are flooding all the corners of the country on a daily basis, bringing health care, we are still unable to quantify a tangible progress in the health care of the population in most of the areas of the country.

4. EVALUATION AND MEASURABLE OUTCOMES In order to determine whether the nursing school initiative has made a significant impact, at the nursing school level, students are asked to complete a mid-year evaluation which ask them to describe the changes the program has made in their professional careers ; HANA sits down with the school faculty to assess its expectations and satisfaction with the program. Success of this program is measured at the end of each year by : 1) The number of graduate students that receive their degrees; 2) Evaluation of board exams (Examen d’Etat) passing scores to assess for improvement; 3) HANA evaluating the nursing students’ knowledge and attitudes towards their patients in a community setting by directly observing their interaction and caring attitude toward different patients; 4) Evaluating hands-on nursing skills in the clinical setting.

HANA seeks, through this education initiative, to train nursing students, who will in turn serve as advocates in their community and alternately improve basic health care in this devastated country, and put in the hands of Haitians the power and knowledge to establish a sustainable health care system in order to have a better future. This initiative was made possible through a grant from the Heartland HCR Manor Care Company, USA. BIBLIOGRAPHY • 1. Guly, Christopher. 2004. “Haiti Emerging from Chaos to Face Health Care Crisis”, Canadian Medical Association Journal, April 27, Vol. 170, No. 9. [En ligne] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC395802/pdf/ 20040427s00014p1379.pdf • 2. Chelala, Cesar and Mariela Cánepa. The Challenge of Haiti, Health A Right for All, Pan American Health Organization (PAHO) report 2011, p. 9. • 3. [En ligne] www.globalsecurity.org/military/world/haiti/health.htm • 4. Wikipedia. 2012. Health. [En ligne] http://en.wikipedia.org/wiki/Health • 5. Ministère de la Santé publique et de la Population. 2013. [En ligne] http://mspp.gouv.ht/site/index.php ?option=com_content&view=article&id= 49&Itemid=28 • 6. Programme des Nations-Unies pour le Développement (PNUD). À propos d’Haïti. [En ligne] http://www.ht.undp.org/content/haiti/fr/home/ countryinfo/ • 7. Guly, Christopher. 2004. “Haiti Emerging from Chaos to Face Health Care Crisis”, Canadian Medical Association Journal, April 27, Vol. 170, No. 9. • 8. World Health Organization. The World Health Report 2007 – A Safer Future : Global Public Health Security in the 21st Century. [En ligne] http://www.who.int/ whr/2007/en/index.html • 9. International Federation of Red Cross and Red Crescent Societies. Annual report 2010. [En ligne] http://www.ifrc.org/Global/Publications/annualreports/ IFRC-Annual-report-2010-English.pdf

Odiane Medacier, MSN, APRN, FNP-C, graduated from Barry University in 1998 with a Master of Science degree in Nursing and board-certified family Advanced Practice Registered Nurse. She currently works as an APRN, FNP-C (family nurse practitioner-certified) in the department of anesthesia at the Public Health Trust/Jackson Memorial Hospital. Mrs. Medacier works as an adjunct professor at Miami Dade College School of Nursing and precepts students in APRN programs including, anesthesia, family, adults and pediatric practices. She also teaches, pro bono, in nursing schools in Haiti where she regularly travels on medical/humanitarian duty. She is currently the chair of education for the Haitian American Nurses Association of Florida. She has received many awards and accolades, including Nurse Practitioner of the year, 2008 for surgical division ; The Nightingale Leadership Award of Clinical Excellence, 2011 ; March of Dime nurse of the year nominee, 2011 and 2012. OMedacier@jhsmiami.org