Training Daze
American nurses reach out to their Iraqi counterparts in an effort to mend the country’s deteriorated health system and introduce modern procedures

By Heather World
September 6, 2004

Col. Linda McHale, RN, knows firsthand the challenges facing Iraqi nurses as they struggle to rebuild a health care system that has suffered years of neglect.

“The smallest thing is an incredible endeavor,” said the U.S. Air Force Reserve nurse who spent the spring as part of a Coalition Provisional Authority medical team helping the Iraqi Ministry of Health implement plans for a new health care system. “I had to get four South African bodyguards to drive me in armored vehicles to the airport to pick up donations.”

Yet McHale sees promise in a country where nurses are dedicated to catching up.

“They’re hungry for information,” she said. The questions she heard most often were about how to get additional training in the United States.

Once the jewel of Middle Eastern health care, Iraq’s medical system suffered during 25 years of war and international sanctions. By the time a U.S.-led coalition invaded in March 2003, medical students studied from photocopied texts of old medical journals and the few remaining nurses used old and scarce equipment to help their patients. Many of the country’s best-trained nurses and physicians had fled.

American nurses, however, are organizing grassroots efforts to help their counterparts in Iraq. Their aid ranges from programs to send textbooks and supplies to organized missions like McHale’s.

McHale said that only about 300 of the country’s 18,000 nurses are college-prepared, and most of those work in academia. The Iraqi medical model is based on Britain’s, so these students are fluent in English.

The majority of the nurses have completed the equivalent of sixth grade, at least, and studied in a three-year technical training program. Unlike the United States, men make up 65% of the nursing workforce in Iraq, she said.

“Unfortunately, a number of those members are illiterate in any language,” McHale said.

Scarce supplies, societal customs, and lack of education contribute to nurses who do more custodial care while physicians perform tasks like taking blood pressure. Even within the limited range of acceptable nursing practices, no assessments are in place to determine levels of expertise, as well as no licensing tests, no accreditation guidelines for schools, no body overseeing license revocation or renewal, and no malpractice laws, McHale said.

Nurses from the Iraqi Ministry of Health — the rough equivalent of the U.S. Surgeon General’s office — identified the strengths and weaknesses of the profession today and developed a plan to improve it.

McHale’s job was to try to help finalize that plan and develop it so that the various outside organizations that would like to help the country would not be duplicating previous efforts.

Setting new standards

McHale helped her counterparts set up a nursing council and an Iraqi nursing association to create a board that would determine licensing and regulation. Despite dangerous travel conditions, 120 nurses (all men) attended a nursing association national election for officers, she said.

She also helped the health ministry nurses write a detailed plan to set up competency evaluation centers in different regions. Certifying who is qualified to be an LPN vs. an RN will allow the Iraqis to determine the scope of practice for each level, she said. McHale would like to secure congressional funds to establish competency evaluations for nurses in Iraq, as well as a rating scale equal to the British or U.S. model.

These funds would include a few million dollars’ worth of equipment, which is also needed for competency evaluations.

“They have no training equipment — mannequins, computers, projectors — all those things were looted after the invasion,” she said.

Brenda Maldonado, RN, a surgical nurse who worked in labor and delivery for eight years, traveled to the Kurdish region in northern Iraq as part of a four-week training effort. She saw equipment, but few who knew how to use it or fix it, she said.

Sponsored by Northwest Medical Teams International and the Washington Kurdish Institute, Maldonado and two fellow specialists in critical care and pediatrics each trained about 10 students six days a week. Although their students had formalized training, Iraqi nursing skills were on par with a nurses aide, she said. None had training in anatomy, physiology, and assessment basics.

The nurses supplemented crash courses on the sometimes mind-numbing scientific basics of nursing with lessons in rudimentary nursing skills, like CPR, blood pressure reading, and knowing the importance of hygiene.

Home front

Nurses like Delmar Imperial-Aubin, RN, are doing what they can from home to feed this appetite for information. Inspired by an article on public health in Iraq that included an address for donations, Imperial-Aubin set about gathering what she could.

She took castoffs left by her school of nursing at the University of Texas, which had cleaned house before moving to a new building. She asked faculty for donations. She went to her 150 colleagues in the cardiovascular intensive care unit at Methodist DeBakey Heart Center in Houston, and together they gathered more books, journal articles, slides of human anatomy, and medical supplies.

“I’m just trying to get nurses to do something they could do as a group,” she said.

The chief nurse executive of the hospital is helping to collect items, too.

Imperial-Aubin has spread the word grassroots-style, buttonholing nurses from around the country at the American Association of Critical-Care Nurses conference in Orlando, Fla.

“It’s going to be a little bit at a time, and it’s going to be grassroots,” said Imperial-Aubin, who will pay out of her own pocket the cost of sending the 100 pounds of materials she has already packed into boxes.

While texts and supplies flow east, other efforts are under way to bring Iraqi nurses to the West. Thanks to donations from private philanthropists, the University of Pennsylvania School of Nursing hosted two Iraqi nurses for one week as part of a broader effort to share cultural understanding, said Afaf Meleis, PhD, FAAN, the Margaret Bond Simon dean of the nursing school.

“It is an opportunity to compare notes,” Meleis said.

Accompanied by McHale — who had taken them to civilian hospitals the week before — the nurses toured University of Pennsylvania’s critical care and pediatric units to see how an American academic hospital is structured. They shadowed a nurse in critical care recovery rooms, visited the birthing center, and surveyed prenatal and postpartum care, she said.

The pair also had an opportunity to talk with faculty members about the structure of the nursing school’s curriculum and what clinical experiences the school provides its students. Talk of classes and courses of study was put in the context of societal needs, religion, and community values, Meleis said.

“We hope we’ll dispel some of the myths they might have about us and that we have about them,” she said.

Text and supply donations will reach Iraqi nurses at this address:

415th CA BN (Civilian Affairs Battalion)
c/o Public Health Team
FOB Danger
APO AE 09392