A second group of students – 5 MECNs and 2 APN – spent 9 days in Oaxaca, Mexico where they provided 40 hours of clinical work and spent 20 hours learning medical and conversation Spanish.
Oaxaca: We have arrived!
Last night students met their “Mexican family”, becoming familiar with the extended families, and the great Oaxacan meals. Sunday, we start our day traveling by van to the various clinics in surrounding areas; up and down rolling, swirling hills. The van slows down with e very “tope”, bump and pothole-traffic never seems to slow down. Next, we have a walking tour of the city, the zocalo, churches, mercado, and of course the chocolate factory-where the owner is glad to give us free treats! Exhausting but such a fun hot day.
From Ophelia: Throughout the day, I may some mental notes, sort of an informal windshield assessment. Water is a big issue here, as I see bottled water sold in the farmacias, and see trucks with “agua solo para los humanos”, booming down the calles, which also ties in with the rule to not throw any tissue down the toilet. One of the biggest issues was the street/road infrastructure; potholes, uneven asphalt, uneven steps. I had to constantly look down to make sure I had good footing. The vehicle emissions smelled very strong here, and I wondered if there was nay smog regulations; no seat belts either for riders on the back of trucks.
From Jason: The outing served as good practice for beginning to perform community assessments using the windshield and informant interview methods I also noted specific health concerns. For instance, when walking through one of the markets in El Centro, dozens of vendors were grilling meat in the enclosed space of the indoor market. This filled the area with a thick cloud of smoke. While it was extremely interesting, appealing, and illuminating to observe this culturally rich scene, I could not help but wonder what effect this smoke would have on the vendors' and patrons' bodies over a prolonged course of time.
From Holly: At a visit to a clinic, I learned that families are given incentives, as coupons for food, clothing, and educational items-for attending the public health educational sessions at the clinics. I think this is a brilliant idea for reinforcement, what a great way to distribute resources to people in need and for improving patient education and health promotion. Primary prevention seems to be an important aspect of the Mexican healthcare system, unlike the US, where it seems to occupy less priority.
Mañana we start off early at a clinic—first by taxi and later we get to ride the bus-just like the locals!
Our first day at the Public Health clinic in the hills: Santo Jacinto
Holly, Chiara, and Ophelia, went off with the “Madrina de Obstetrica”, the neighborhood promotora. Her job was to make home visits to the expectant women, provide maternal-infant health education, or in some cases, to see if infants were already born and required clinical appointments. We heard stories of how some women live so far away from the clinics and hospitals, that they sometimes deliver the infants at home, or on the winding rolling hillside.
The remaining students teamed up with the physicians or nurses inside the clinic, and others remained in the patio and observed the “charlas” conducted by the social worker or therapist, where families learn strategies on how to manage stress, prevent domestic violence, or ways to protect children from drowning in the wells, or other childhood accidents.
From Holly: Jasmine, la madrina, provided patient education on signs and symptoms of labor, she reminded them of clinical visits, the importance of nutrition and breast-feeding. It was interesting that all the expectant mothers and new mothers were living with their mother or grandmothers for help with the birthing process and postpartum recovery. The rough terrain in the community made me wonder about access to the clinic or hospital, but the madrina explained that a birth plan is established with the family, including ways to gather support from neighbors. The use of madrinas is a wonderful way for increasing access and health education; they are greatly respected.
From Chiara: The first day in the clinic was eye opening. They had a lot of health education listed on posters; I wish we had more of this in the US. It was interesting that the nurses insisted on using their title as “enfermera xxx”. Placing the title of nurse in front of their name shows how proud they are, and I feel that we could take that back with us to the US, as I admire their strength. I also feel that since the nurses don’t have a choice as to where they work, being a nurse in Mexico is so much more honorable; to leave your family for your job is so noble, I have much respect for them.
From Jason: I observed a workshop on preventing accidents in the workplace, home, school, and the neighborhood streets. I was able to gain some insight on the incentive system, where they use “targetas de oportunidad”, these track attendances at the workshops and visits to the clinic. Each family has one of these cards and each family member is noted on the card. Whenever a member attends, the card is signed off. Incentives include material benefits like school supplies for families. The incentive systems m works fairly well, all seats were filled in the workshop. It is difficult to hear the therapist at times, because of the noise, as the workshop is held outside, in what seemed like a carport; there were no walls, and at one point someone was revving up their care next to the meeting site, and planes flew by. All of this was distracting. I thought of how heavy tarps would be a cost effective way of keeping out some of the noise.
This is our 2nd and last day in the public health clinic in Las Lomas. We are learning all about the city and buses, as it only costs us 6 pesos, less than $ .50 US cents! Riding the bus is different than in the US, as passengers are talking, the bus driver waves to people in the street, and the music gets louder as more families get on board. The passengers are friendly, many offer us their seats, they're very respectful and eager to help us find our way in this beautiful colonial city. After our day in the clinics, we rush out to get white uniform tops -the hospital will not allow us to enter tomorrow unless we all wear white uniforms! Then, we rush off to for Dra. Magaly's presentation on Mexico's health care system, including IMSS, ISSSTE, and the Seguro Popular program. Some very long, but also very exciting days. We talked about how we could have more free time, but students do not want to miss any clinical, hospital, or the spanish lessons-we don't want to miss anything.
Mañana, we go to the hospital!
I spent the morning with a doctor. He always spends a great amount of time with the patients; he took time to provide education and prevention information on diet and health (clear water techniques, signs and symptoms of illness and what to look out for). He even did a complete family intake on a patient and asked about her great-grandparents' health history-now that's extensive!
He took so much time to with the patients, which can reinforce the health information. In the US, we may be showing you out the door while we're giving you education- and then we expect patients to follow the instructions. Seeing this allows me now to better understand how immigrants may clearly expect very different experiences when they come to the US.
We saw a mother and her two young children today in the clinic. Both boys had diarrhea and stomach pain, and one boy had a painful penis. We found out they had been eating top ramen noodles for months. The doctor explained to the mother that this was not nutritious, because it's "like eating plastic." (Later, the doctor explained that the noodles turn hard, like plastic in the child's stomach, and our nursing instructor relayed how ramen noodles have become popular in Mexico-replacing rice as a major staple).
The younger son also complained of penile pain, as he had an embedded yeast infection. The doctor picked the pieces of fungi out, with the child screaming. The entire family was then educated on hygiene; and then the doctor told the older brother that he needs to teach his little brother hygiene. It was really interesting how they incorporate the entire family into health care in one encounter.
Gem compared her experiences at the clinic with her experiences at the Public Health Department in Los Angeles:
I spent the day with nurses, and surprisingly they were all male. All vital signs were taken with non-technology based instruments, temperatures taken with a thermometer, and manual blood pressures and weight taken via a non-digital scale. Instead of pre packaged alcohol wipes, there were cotton balls soaked in alcohol. We talked about how many community clinics in L.A. also function similarly, due to finances. It was also interesting to see a nursing student functioning independently, as opposed to the supervision one gets by a liaison in the US.
After spending 2 days in a hillside public health clinic, we are now ready for the Hospital Civil, the major public hospital in Oaxaca City. Later, we will attend a presentation by the Director of Nursing Education on the Nursing Scope of Practice.
Our day starts very early (7am); everyone on the bus can tell that we are nurses. Within 20 minutes, the bus driver and several passengers let us know when we're near the hospital- there's no way we can miss our bus stop with everyone looking out for us. Outside the hospital, there are long lines of families with children waiting for the doors to officially open. Some will be taking care of ill family members; others are waiting for the lab, pharmacy, or signing up for future medical appointments.
Our group is very excited; first, we are all wearing white "Filipinas" (uniform tops), white pants, white shoes-but no "cofia." Not having the nursing caps is a major cultural lesson, as the nurses are proud to be wearing cofias, they are proud of their profession and the uniform, they do not understand why we do not wear them. These nurses quickly let us know that they wish to be identified as "enfermeras." We meet Licenciada Enfermera Irene, the Jefatura de Enfermeria (Licensed Chief/Director of Nursing), Enfermera Nelly (one of our favorite nurse managers in the Adult Urgent Care), Enfermero Gabriel, and Jefa Rosa (Chief Nurse) in the Pediatrics Urgent Care.
I observed how a nurse in the medical surgical unit measured a patient's central venous pressure using a ruler, or a very non-technical fashion; one that I'm not used to. The most meaning lesson was how much of the patient care is often carried out by family members; hygiene, massaging, turning, feeding, mouth care, combing hair. I wonder if having family members provide this care results in greater benefits to the patients. As a student, I can research the question of whether family caregivers provide better, worse, or similar outcomes as compared to care given by trained CNAs in the US. But for now, I need to observe
Today was quite an eye-opening experience. There are many similarities here; patient ratios, supply room, nurse station, morning shift reports, but there are also difference. One of the most glaring lessons was the lack of patient privacy. Most of the rooms house 6 patients. There were large glass windows and from the hallways, you can see the patients, even though there are curtains between the patient beds. There are so many people in the hallways, one can easily see the PMIs; patient ID, age, etc on a label above the patient's bed; the chart and nurse's notes are on the side table at the foot of the bed. Culturally, however, I did not notice that family looking uncomfortable with the lack of privacy, as it seems to be the norm for doing things in the hospital. I could tell that some nurses had real dedication and passion and want to elevate the profession. Enfermera Elena stressed that we are not the doctor's assistants, but team members. We talked about the cofias (nurse caps), and she agreed that should move away from the traditional clothing. Another enfermera is studying palliative care, and another is a wound care nurse. All students reflected on the limited resources; including manual typewriters used for typing hospital notes, limited supply of gloves and sterile, safety practices in the hospital.
Many of the used instruments go through a two-step cleaning process in the ward, and then they go to Central Supply for packaging. An auto clave is available, but very few instruments are sterilized this way. Much of the equipment, like masks, oxygen tubing, etc, is cleaned so simply. The lack of regular use of gloves was concerning. The nursing coordinator said that gloves were available. Our medical guide agreed that gloves were available, but if all the gloves were to be used, it may take days before they get additional supplies, so it may be that they use these sparingly.
Mañana, we visit a University and have a lively exchange with nursing students!
We continue our International program; getting immersed in public health concepts, learning about Mexico's Health System, doing public health in urban and rural areas; plus our service learning and presentation at El Centro de Esperanza, an agency that provides educational support, nutritious meals and health services to over 600 children from one of Mexico's most disenfranchised groups-the Indigenous Zapotec population.
Our day starts with Dra. Magaly, a family practice physician (our friend and collaborator) at the University, and La Escuela de Enfermeria. We were scheduled for a tour and informal visit with a group of nursing students. Instead, we were formally ushered into a large hall and greeted by the Rector de la Universidades (equivalent to a Chancellor), administrators, a large contingent of Mexican estudiantes, and photographer. The Oaxacan students welcomed us in English, Spanish, and a Zapotec dialect. After the formal presentations, both groups of students had lively exchanges about the nursing curriculum, clinical experiences, requirements for practice, and nursing roles. Everyone was impressed with the similarities between the US and Mexican nursing curriculum, as well as the differences in resources and technology available in the US. In Mexico, the nursing school emphasizes that students are trilingual (Spanish, Zapotec, and English). In the skills lab, we saw how students were practicing a hand wash demonstration in 3 languages; and we saw students practicing how do perform a pelvic and pap smear on a mannequin; this is all part of the BS curriculum!
We had expected a short visit-but as often happens with Latino themed cultural exchanges (familismo), we spent one-half day making friends, exchanging ideas, sharing snacks, and lively discussions as we made plans for future exchanges.
We then rushed to Centro de Esperanza and students handed out their large bags of donations. The children loved the SON educational presentation (hand washing and the Dracula Cough), and of course the Salud "Loteria" game, with great prices (tooth brushes, toothpaste, hand sanitizers, pencils, and other school supplies). Another highlight-Jason's guitar playing and original song-please check the photos and video!
I learned so much about the rigorous nursing program; it is amazing that they are required to do one year of service (nursing) for their time in school. I like how they do their semester courses, followed by one month of clinical-it makes much sense to do it this way. I'm reflecting on how the school focuses on the native "mother tongue"- the Mexican students demonstrated how they are able to teach hand washing in 3 languages. It was great to learn how they honor cultures and language-this shows humility and respects for others. In the states, we expect immigrant to acculturate.
At the University, there was a collective gasp from the Oaxacan students when we talked about our 2-year entry-level maser's degree program. In Mexico, for a licensed nurse, it takes 4 years of schooling plus one year of service and the government places nurses in communities with the greatest need. However, some similarities included the nursing curriculum; including courses in public health, research, ethics, and of course-nursing diagnosis and care plans.
During the student exchange, I felt that our program promotes humanistic and holistic approaches to nursing care, but maybe not to the same extent as some Latin American countries and they incorporate family more into the care. The family focus is important, as it affects a good portion of the patient population, especially in Los Angles. The emphasis on public health is also different, as in Oaxaca, public health is taught very early in the curriculum, while we have public health at the end of our program. Hopefully, with health care reform in the US, we will be able to incorporate a more practice that emphasizes primary care and prevention more.
I met Mannie at the Escuela de Enfermeria. He was fluent English speaking, as he explained that he lived in North Carolina for 8 years prior to starting the nursing program. I learned that they have a lot of presentations and projects throughout the program-just like MECNs! We will be exchanging emails and will try could learn from each other.
At the Centro de Esperanza, we finally got to do the presentations and to distribute the donations that Gem and I had been coordinating for almost 2 months. We were a success with the children! We were very happy with the amount of donations we received from the SON staff and students. I hope we continue these programs next year.
We spent the day with Enfermera Letty in a rural community located one hour from the city of Oaxaca. This area is one of the poorest in Mexico, with a almost 900 indigenous residents. The majority of the population speaks Zapotec, and most have less than a 6-grade education. Enfermera Letty introduced us to the new physician assigned to the community clinic (he just started the mandatory 1-year of public health service "servicio social"). The 3-room clinic serves as the emergency care site, labor/delivery room, and all around family practice site. La enfermera y el doctor work as a team and provide whatever medical/nursing care is required in this community.
Enfermera Letty took us on her daily rounds; this is how she updates census and demographic data (including new births, deaths, changes in health status, etc), conducts community risk assessments, measures the chlorine content for the water, checks the water level in the river, assesses the cemetery for decaying flowers, stagnant water sources and other environmental health risks. She also does home visits, performing whatever nursing care is needed, along with doing nutritional assessments and providing health education. Today, she was visiting 3 families, assessing if the families had complied with her public health instructions; including instructions on removing overgrown weeds and hazardous materials in the entryways and yards. The families had also been instructed to cover deep holes in the yard (future wells or toilets); and to separate the children's play area from the farm animals (burros, pigs, turkeys, chickens).
The families routinely waved and greeted Enfermera Letty-although they looked at us suspiciously. Once Enfermera Letty introduced us, the families smiled and allowed us into their yards. Enfermera emphasized that without the trust and the interpersonal relationship she has developed with each family, she would not be able to do her job ant maintain the community healthy.
It was baffling that the nurse had her master's degree, had worked in this community for eight years, but she did not want to move to another community- although the government wanted to move her. She preferred to remain with this community, where she was given the title of nursing ancillary staff, plus she was given less pay (with her degrees, she could earn more by moving to another site). This is true dedication to the community.
The cultural differences here were also very interesting. At one of the homes we visited, the mother was 21 year old, with three children. She lived with her husband and his family, with two separate living areas on one property. This goes along with the great sense of family and community. The families are very close, they can help each other, and take care of each other. I love the idea of the close family, all working together to do better. I really enjoyed being part of the care team approach as they intimately assessed the families in their homes.
The walking assessment was truly an eye opening experience and a bit of a culture shock. This community was very poor; most of the homes were made of aluminum and recycled wood. These makeshift living quarters housed not only families, but also animas.
This has been a huge learning opportunity, as we have been exposed to the a culture and the problems facing a health system. I feel that I will return more culturally competent with an idea of why certain barriers exist when caring the Hispanic population. I also realized that I take for granted all we have in the US, including disposing of supplies so easily, the number of medications we have available, rapid lab results, privacy, electronic charting, and information at the push of a button. This experience has definitely had a positive impact on me and the way I think about healthcare. Thank you for giving us the opportunity to grow not only as a student nurse, but as a person as well.