Collaborative partnerships are important to develop and maintain quality clinical relationships, particularly in international settings. Collaborative partnerships are important to develop and maintain quality clinical relationships, particularly in international settings (Leurer et al., 2011). Whether focused on clinical study abroad experiences, medical missions, or other service learning projects, these partnerships must go beyond formalized agreements. To truly have a collaborative partnership the values of both partners must be understood and respected; both partners need a voice in what will be done and how it will be done (Baumann, 2012). In order to collaborate successfully at this level, it is essential for both parties to have an understanding of each other and their needs and experiences Yet, often partners in international collaborations know little about each other.

We authors have been involved in a number of service-learning activities in the country of Honduras; and we have noted this lack of understanding in working with Honduran nurses. Although little is known about Honduran nurses, Honduras remains a frequent site for medical mission work and a common site for study abroad programs. Honduras is located in Central America. It is bordered by Nicaragua on the south, El Salvador to the west, Guatemala to the northwest, and the Caribbean Sea to the north and east.

To truly have a collaborative partnership the values of both partners must be understood and respected... Santa Cruz de Yojoa was chosen as the site for the study described in this article because we previously had led three study abroad programs in this area of central Honduras, in the Department of Cortés Region. During these programs, we worked with rural health professionals to facilitate opportunities for students from the United States (US) to provide nursing care and health education to the local Hondurans. We also worked as advocates for a grassroots effort to build a hospital for the rural underserved population of Santa Cruz de Yojoa (Smit & Tremethick, 2013; Tremethick, Smit, Retzloff, & Krol, 2011). Each of these activities was guided by the needs of the authors’ Honduran partners. These needs were identified through Skype calls and email communications with a private practicing physician, a physician in charge of the local public clinics, and a bilingual educator in the Santa Cruz de Yojoa Region. Activities that were identified and addressed included hand washing, teeth brushing, making healthy food choices, and understanding the importance of folic acid for women of childbearing age. Contact with nurses was made once we were in country; the nurses in the rural clinics provided guidance on student participation in the clinical settings. However, in spite of all of these experiences, we still had little understanding about the Honduran nurses with whom we have partnered.

In this article, we will describe the current status of healthcare in Honduras and our study to explore the work of Honduran nurses, their goals, and the challenges they face. We will present our findings, including busy workdays and limited resources, as well as nurses’ internal rewards for their work, and offer suggestions for future international initiatives. We will conclude that understanding the experiences, perceptions, and needs of nurses in international settings is critical for developing collaborative partnerships that meet mutual goals for all members of the partnership. The goal of this article is to fill a void in the nursing literature by providing guidance for the development of collaborative, international partnerships.

Healthcare in Honduras

This section will describe the health status of the Honduran people. We will also discuss the current status of nursing in this country.

Health Status of the Honduran People

...per capita spending on healthcare services in Honduras was $134 (U.S. dollars) in contrast to the 2009 per capita spending in the US of $7,960. Nursing in Honduras takes place in a setting quite different from that of developed countries, such as the United States (US). Sixty-six percent of the Honduran population live in poverty, and 49% live in extreme poverty (Zeribi & Marquez, 2005). Additionally, there are limited financial resources allocated to the healthcare system. According to the World Health Organization (WHO, 2009), per capita spending on healthcare services in Honduras was $134 (U.S. dollars) in contrast to the 2009 per capita spending in the US of $7,960 (WHO, 2012).

The health of the Honduran population, as measured by health indicators, reflects the limited resources available for healthcare. Infant mortality rate is a commonly reported health indicator referring to the probability of infant death by age one per 1,000 live births. Honduras has an infant mortality rate of 20 compared to the WHO’s ‘Region of the Americas’ (a geographical area made up of 35 countries in North, Central and South America) infant mortality rate of 14, and the U.S. infant mortality rate of seven (WHO, 2012). The maternal mortality ratio reports the number of deaths of pregnant women or deaths within 42 days of being pregnant, per 100,000 live births. Although the maternal mortality ratio in Honduras has decreased significantly, from 220 per 100,000 live births in 1990 to 100 per 100,000 live births in 2010, it remains well above the maternal mortality ratio of the ‘Region of the Americas’ of 63 per 100,000 live births in 2010 (World Health Organization, 2012).

In addition to limited funding for healthcare, a change in the types of diseases the Honduran people are experiencing further challenges the country’s ability to provide adequate healthcare. Honduran healthcare providers continue to care for patients with infectious diseases, such as malaria, dengue, and tuberculosis. At the same time, there are increasing numbers of Hondurans requiring care for chronic diseases, such as cardiovascular disease and cancer (WHO, 2012). This increased demand for chronic disease care greatly strains the limited financial resources for healthcare in Honduras. In summary, infectious and chronic diseases strain the limited human resources available to the Honduran healthcare system.

Nursing in Honduras

Within Honduras, there are two levels of nursing practice, professional nurses and auxiliary nurses. Professional nurses make up 21.2% of the nursing workforce in Honduras (Malvárez & Castrillón, 2005). According to the International Association of Universities (n.d.), a professional nursing degree in Honduras is awarded to nursing students after four years of study. To be accepted into professional nurse educational programs, students must complete secondary school through grade 13 (World Bank, 1998). Professional nurses receive their nursing education through the National Autonomous University of Honduras (Pan American Health Organization, 2001) and upon graduation must provide one year of Social Service during which time they serve the needs of a community for a small stipend.

Due to the low number of professional nurses, auxiliary nurses play an important role in Honduran healthcare and constitute the largest segment (78.8%) of the nursing workforce (Malvárez & Castrillón, 2005). Auxiliary nurses are technical nurses with two years of nursing study. Auxiliary nurses need only three years of secondary schooling (7^th-9^th grade) prior to admission to nursing school (Villanueva, Mendoza, Aguilar, Rodríguez, & Vernon, 2001). The Division of Human Resources of the Ministry of Public Health is responsible for educational institutions that train auxiliary nurses (Pan American Health Organization, 2001). The salary of an auxiliary nurse is 30% less than that of a professional nurse (Malvárez & Castrillón, 2005).

Honduras has a low nurse to population ratio... Honduras has a low nurse to population ratio with 0.32 professional nurses per 1,000 people in Honduras. This is in contrast to 9.72 nurses per 1,000 people in the U.S. (Malvárez & Castrillón, 2005). Inadequate funding for healthcare results in low pay with the average Latin American professional nurse earning $400-$500 U.S. dollars per month (Malvárez & Castrillón, 2005). Low pay promotes nurse migration to other countries where nurses can earn more money (De Leon Siantz & Malvárez, 2008; Sena, Seixas, & Silva, 2007).

This discussion of healthcare and nursing in Honduras provides an overview of the setting in which Honduran nurses work. However little is known about the experiences and perceptions of Honduran nurses themselves. Ailinger, Najera, Castrillón, and Manfredi (2005) have pointed out that nursing research in Latin America takes place primarily in and by countries with nursing doctoral programs. With no nursing doctoral programs in Honduras, little attention has focused on understanding characteristics of Honduran nurses and their day-to-day work. Understanding these experiences and perceptions is important to the numerous healthcare workers and nurse educators who forge collaborative relationships with nurses in Honduras.

Low pay promotes nurse migration to other countries where nurses can earn more money. Decamp (2007), in his discussion of ethical issues related to medical missions, emphasized the importance of assuring community involvement, providing culturally competent care, and addressing the long-term impact of community outreach. Developing collaborative relationships with Honduran nurses to address these issues is particularly important when one considers that Honduras is the most frequent site for medical missions (Martiniuk, Manouchehrian, Negin, & Zwi, 2012). Kulbok, Mitchell, Glick, and Greiner (2012) support work with nurses in developing countries and have suggested that “two-way exchanges should be evaluated to identify successful strategies as well as barriers to success” (p. 18). Our exploratory study sought to provide an increased understanding of Honduran nurses, information that is needed for developing collaborative partnerships.

Study Methods

This section will describe the instrumentation we used in our study. In addition, we present our data collection procedures, and describe our sample.

Instrumentation

For this study we developed a structured interview protocol with both demographic questions and qualitative, open-ended questions to give the Honduran nurses the freedom to respond in ways that might not have been expected by researchers in the developed world. The structured interview protocol enabled researchers to ask the same set of questions of each participant. These qualitative questions were designed to gain an understanding of the work of Honduran nurses, what these nurses perceived as their rewards or difficulties, and their educational goals. These areas were deemed important by the researchers to facilitate a better understanding both of the Honduran nurses and the best ways to build collaborative relationships with these nurses. Once developed, the interview protocol was sent for review to three nurse experts who had worked with nurses in Honduras and who had experience conducting research in Honduras. Parts of the interview protocol were changed in response to suggestions by these experts. The instrument was then translated to Spanish by a professional translator and sent to the area of Honduras in which the interviews would be taking place, where it was back translated to English by a bilingual native. Minor changes to the questions were made to conform more closely to terminology used in the local area.

Quantitative questions were used to establish participants’ age, gender, level of education, practice setting, number of years in nursing, and the number of years in current nursing position, as well as whether the nurse spoke English and whether the participants enjoyed their role in nursing. The qualitative, open-ended questions included the following:

1. What made you decide to become a nurse?
2. Describe your typical day. What kind of activities do you perform?
3. What aspects of nursing do you find rewarding?
4. What aspects of nursing do you find difficult?
5. Would you like to continue your nursing education?
6. What type of continuing education are you interested in pursuing?
7. What barriers do you see to continuing your nursing education?

Data Collection

After approval from our university institutional review board, data collection began in the Santa Cruz de Yojoa Region of Honduras. Data were gathered through face-to-face, structured interviews conducted by the primary author with the assistance of a native-speaking interpreter who was a teacher in a local Honduran bilingual school. First, each nurse-participant was given and asked to read an informed consent page describing (in Spanish) the study, the nurse-participant’s role in the study, and the confidentiality of responses. Participants read the informed consent, and the interviewer (first author) asked if they had any questions. Participant questions were translated from Spanish to English; then the first author answered the questions in English, and these answers were translated to Spanish by the interpreter. The questions were few in number, but those that were asked focused on confirming the time commitment and inquiring how the information would be used. The interview did not begin until after the nurse-participants indicated that they had no further questions and had signed the informed consent. Participating nurses received 200 Lempira (approximately 10 U.S. dollars) as compensation for their time during the interview. During each interview, the primary author collected the answers by immediately writing the interpreted responses on the interview protocol sheet. On average, interviews lasted 40 minutes.

Sample

Convenience sampling was used to interview 15 nurses employed in government clinics in Honduras. Nurses, who were attending a national, nursing day celebration in Santa Cruz de Yojoa, were recruited to participate through collaborative efforts with the head physician of public health clinics in the Santa Cruz de Yojoa Region.

The 15 interviewed nurses were between the ages of 23 and 49 with a mean age of 36. They had worked as a nurse for between 0.5 years and 23 years (mean 8.70 years) and had held their current positions between 0.5 years and 18 years (mean 5.83 years). Eighty percent (12) of the nurses were female and 20% (3) were males. Twelve of the nurses were auxiliary nurses and three were professional nurses. All of the nurses were employed in government clinics with six nurses employed in rural clinics and nine employed by a clinic in a town of 12,000 people. Two of the nurses spoke some English. All of the nurses reported enjoying nursing. Four nurses (26.7%) reported that they had worked with nurses or nursing students from the U.S. in the past.

Data Analysis

Quantitative data (including age, gender, level of education, nursing setting, number of years in nursing, number of years in current nursing position, whether the nurse spoke English, and whether participants enjoy nursing) were analyzed with SPSS using descriptive statistics. Qualitative data were initially analyzed by the first author who used NVivo 9 software to code, retrieve, and help manage the interview data. NVivo software, developed by QSR International, helps researchers manage, analyze and report on unstructured data, such as interviews (QSR International, 2013). Themes that characterized the experiences of the Honduran nurses were identified by the first author through content analysis. Credibility of the findings was established through validation of the categories by the second author of the study. The second author, who has published several qualitative studies in peer reviewed journals, read through the responses of all of the participants and confirmed that the themes identified by the first (primary) author were an accurate reflection of the data.

Research Findings

We will begin this section by sharing our quantitative findings. Presentation of our two qualitative themes will follow.

Quantitative Findings

All participants (N=15) stated they would like to continue their nursing education. When asked what type of continuing education was of interest, responses varied by current level of education. Of the 12 auxiliary nurses, eight wanted to become professional nurses. Three of these auxiliary nurses reported an interest in pursuing technical training which, in Honduras, can be completed by auxiliary nurses with additional training to provide women’s reproductive services, including intrauterine device insertion (Vernon, 2009). Of the three professional nurses, one wanted to pursue a master’s degree in nursing, one reported an interest in public health or human resource management, and the third stated an interest in additional study, but did not know her preferred area of study. None of the participants was currently seeking additional education.

Themes Based on Qualitative Data

Two primary themes emerged with analysis of the qualitative responses. These themes, (a) altruism: caring and helping others, and (b) impact of poverty and lack of financial and human resources on nursing practice, will be presented below.

Caring and helping others was an important theme which emerged...Theme 1: Altruism: caring and helping others.Caring and helping others was an important theme which emerged when nurses spoke about their work, why they became a nurse, and the difficulties they experienced as a nurse. When asked about their typical day, nurses reported very busy days that were filled with activities, such as taking vital signs, giving vaccinations, cleaning wounds, and following the doctors' orders in regards to administering medications. One nurse shared, “If we have time we have lunch, if not we will attend people. When the clinic is full of people I do not feel right eating.” Nurses also reported some additional activities. One such activity was ordering medications when a physician was not present, a permitted activity for professional nurses in Honduras, when using a specified protocol.Additionally nurses described how they provided reproductive education in the schools. For some nurses, the work varied by the day of the week.

Altruism, described as “a concern for the welfare and well-being of others” (American Association of Colleges of Nursing, 2008, p. 27) was also evident in other nurses’ responses. When asked why they became a nurse, participants shared intrinsic motivators that revolved around caring and helping others. One nurse explained, “I have always wanted because my mother is a nurse and my father is a pastor. It is the only way to help society from the heart.” Another participant stated, “I like helping people in need. I like being a nurse. Nursing is beautiful because we help people.”

When asked what aspects of nursing they found most rewarding, nurses focused on the helping process, describing their work with patients as a “relationship,” a time to “see healing in the children,” and an opportunity to “share experiences with patients.” These descriptions were expressed within the helping context, as nurses shared how their work was rewarding. One nurse emphasized the rewards of helping by adding, “Helping people is the most gratifying thing I can think of.”

Theme 2: Impact of poverty and lack of financial and human resources. The issue of poverty and lack of resources in Honduras was another important theme... The issue of poverty and lack of resources in Honduras was another important theme, permeating the nurses’ responses to each question. In response to why they chose to become nurses, one participant stated, “I liked medicine since I was a girl. But, because there was not enough resources, I could only get to be a nurse. I could not be a doctor.” Some of the nurses shared that they became a nurse only after a third party paid for their nursing education. Another focus on poverty (lack of resources) related to choosing to work with those in poverty, as noted in the response,“...to serve the poorest people.”

When discussing rewards for work as a nurse, once again poverty played a role in the responses of nurses, with some pointing out that the patients they served had inadequate financial resources. One nurse noted a desire to “help people who really need it [as] there is a fair amount of the population that have economic issues and cannot afford medication and we can help them.”

The theme of poverty, and lack of resources related to nursing personnel, supplies, and medications, was demonstrated as important when nurses were asked what was difficult about their job in nursing. This lack of resources, coupled with the perceived intrinsic rewards inherent in the helping process, created a very difficult situation where nurses had difficulty providing care they believed patients needed. One participant shared:

To give quality care to patients [is hard] because here one nurse has to do a lot of work. In my case, there is a large amount of people coming to the clinic and there are few of us. You have to do all the work that has to be done and there is only you to do it. We sometimes do not have enough people and you have to attend to people with accidents and burns.

Other nurses reported feeling at a loss to help those that needed care outside of their scope of practice. This was noted in the following comment: “Sometimes there are cases in which I cannot help people. It is out of my hands. They need doctors and they [doctors] are not available. I feel bad when that happens.”

When asked about barriers to pursuing additional education, participants identified multiple challenges. As would be expected when considering the low salary for nurses in Honduras, lack of financial resources was often discussed. For some nurses, the need for money to further their education was in direct competition with the need to use scarce financial resources for care of their families. Nurses shared difficult choices saying, for example, “Money is one of the barriers. My son is in private school. I could study but I would have to take my son out of the bilingual school.” Access to nursing school was also a concern due to the cost of travel, as indicated by the nurse who replied, “The issue would be that you could not travel back and forth in a day. Classes are Saturday and Sunday and you must stay overnight.”

Discussion

The relative percentages of auxiliary and professional nurses interviewed for this study closely resembles the percentages of nurses working in Honduras. Professional nurses in Honduras include 21.2% of the nursing workforce (Malvárez & Castrillón, 2005). In our study, 20% of interviewees were professional nurses. Auxiliary nurses consist of 78.8% of the Honduran nursing workforce (Malvárez & Castrillón, 2005) and 80% of our study interviewees.

Nurses reported that their perceived rewards were centered on caring and helping others... None of the nurses identified salary as a reward or as a reason to become a nurse. Nurses reported that their perceived rewards were centered on caring and helping others. This is very similar to a recent meta-analysis of studies on nursing satisfaction including nurses from several countries (US, Australia, Canada, Norway, Italy, Ireland, China, Jordan, United Kingdom, and South Korea) and reported by Hayes et al. (2010). While the results of this meta-analysis were multifaceted, nurse-patient interaction was noted to be important to nursing satisfaction. Hayes Bonner, and Pryor have stated, “Direct patient care seems to provide a sense of value and reward to nurses. This was particularly noticeable in the qualitative literature” (2010, p. 810). None of the nurses identified salary as a reward or as a reason to become a nurse. This may be a reflection of the low salary paid to nurses in Honduras.

Negative experiences and dissatisfaction with the lack of resources for healthcare services reported by Honduran nurses are also consistent with other studies. In a study of healthcare dissatisfaction in Latin America, 43% of Hondurans reported being dissatisfied with healthcare services (Kim, Blendon, & Benson, 2012). Perceived difficulty in access to healthcare was reported by 29% of respondents (Kim et al, 2012). Pearson, Stevens, Sanogo, and Bearman (2012) noted that in interviews of Honduran patients in three medical mission sites, between 66% and 94% of patients reported that one of the barriers to accessing healthcare was the crowding of healthcare facilities. Additionally many of these patients were unable to access diagnostic testing. Between 20% and 78% of patients reported an inability to access blood tests and 29% to 86% reported an inability to access radiology (Pearson, Stevens, Sanogo, & Bearman, 2012).

Whether working with Honduran nurses in a mission setting or with students in a study abroad program, it is vital to understand the high demands on Honduran nurses of the day-to-day work. When planning for any type of service learning experiences, collaborating with Honduran nurses would allow the Honduran Nurses’ work schedules and the needs of their patients to be reflected in the services to be offered. For instance, during our study Honduran nurses quickly shared the tasks for which they were charged (responsible). They knew which days of the week were busier. With this knowledge, Honduran nurses were in a good position to know which experiences would be available for international students and when the nurses would be available to work as preceptors for these students.

One of the criticisms of a medical mission is that the volunteers bring resources into a country, such as Honduras, but then leave without being able to provide follow-up care (Decamp, 2007). The follow-up care then falls to the Honduran medical system. Decamp (2007) uses, as examples, the follow-up needed for antibiotic administration, if there is an allergic reaction, or the development of an ulcer after taking too much ibuprofen with too little food. Consultation and collaboration with international nurses to explore ways to address this necessary follow-up care is important.

... providing information and resources for continuing education could help to strengthen ongoing, international partnerships. Furthermore, assisting these local nurses in their educational advancement would help to establish mutually beneficial partnerships by giving back to them. All of the nurses in this study wanted to continue their education, yet all of the nurses cited financial and access barriers to pursuing an advanced degree. Many medical mission groups seem to be unaware of this interest in, and need for continuing education. In a study of short-term medical missions, only 45.1% of participants perceived training for local health workers as an important goal (Chiu et al 2012). Because literally all of the nurses interviewed wanted to continue their education, providing information and resources for continuing education could help to strengthen ongoing, international partnerships. For example, nurses with access to the Internet and a computer, perhaps through a local library, may be able to pursue Internet-based continuing education options, such as www.nextgenu.org/,which provides free higher education, accredited, online classes. Honduran nurses may also have ideas for removing barriers and for developing programs to address their educational needs. It is important to include Honduran nurses in these discussions.

Implications

The findings from this study indicate that Honduran nurses focus on providing the best possible care for their patients. However they are often lacking human and financial resources to provide this level of care. The Honduran nurses interviewed during this study were welcoming of international collaborative efforts. Some suggestions for those planning service learning initiatives, including medical missions and study abroad programs in Honduras, or other developing countries, are described below.

Preparation before medical missions:

• Prior to leaving, learn about medical care resources in the region where you will be working. If there are none, determine where the closest resources are located.
• Make contact with healthcare professionals in the closest medical site:
  • Learn about the health professionals’ current concerns with infectious and noninfectious diseases.
  • Discuss how you can work in synergy with local healthcare providers to provide continuity of care.
  • Learn what resources would be most helpful to local health professionals.
• Consider providing educational opportunities for nurses, while also encouraging nurses to share their expertise. Encourage nurses to determine and share how to best address their educational needs.

Preparation before study abroad programs:

• Identify clinics in the area where students will be working.
• Travel in advance of the experience to meet with nurses to discuss the opportunities that will be available to students in clinics. Find out what health messages nurses in that area see as important for bringing into the school or community setting.
• Learn from local nurses what they perceive as necessary information for students to have prior to working in the clinic.
• Learn from local nurses what supplies to bring so students can practice in a safe manner (e.g. gloves, hand sanitizer).
• Schedule your study abroad so that you and your students will be able to work the days and times that work best for nurses.
• Ask nurses to identify how your program can help to meet nurses’ educational needs.

Study Strengths and Limitations

There were strengths and limitations to this exploratory-descriptive study. Strengths included the consistency of a single, doctorally prepared interviewer conducting all interviews. A broad sample (perspective) was obtained in that none of the nurses refused to participate in the study. Accuracy and interpretation were facilitated by creating the interview protocol in English, then translating it to Spanish by a professional translator, and then translating it back to English by a Honduran in the local area, to ensure that the terminology used matched that used in the local area. Credibility of the findings (themes) was established as data was initially analyzed by the primary author, who had also conducted the interviews, and then validated by the co-author.

Limitations of this study included the use of a convenience sample, the collection of data in a single area of Honduras, and the participation only of nurses employed by the Honduran government. Due to the lack of random sampling and the small area of Honduras where nurses were recruited, the results of this study cannot be generalized to all nurses in Honduras. Future studies are needed to address these limitations.

Conclusion

Understanding the experiences, perceptions, and needs of nurses in international settings is critical to develop collaborative partnerships that meet mutual goals for all members of the partnership. Faculty members working with students in study abroad initiatives, nurses working with medical missions, and the in-country nurses can all benefit from collaborative partnerships that promote the development of sustainable programs to address community needs.

...Honduran nurses have a focus on caring and helping others in a work setting characterized by inadequate human and financial resources. While being mindful of the limitations of this exploratory study, the results provide a basis to begin to understand the rewards and challenges of Honduran nurses. Study findings suggested that Honduran nurses have a focus on caring and helping others in a work setting characterized by inadequate human and financial resources. Although these nurses are very busy in their practice setting, they receive great internal rewards for their work with patients and were found to be very receptive to working with international students. An awareness of such factors, as well as pre-program consultations with international nurses, can lead to a greater understanding of the needs of the local nurses and the development of creative and successful international, collaborative partnerships.

Author

Mary Jane Tremethick, PhD, RN, MCHES, FAAHE
Email: mtremeth@nmu.edu

Dr. Tremethick is currently the Associate Dean and Director of the School of Health and Human Performance at Northern Michigan University in Marquette, MI. For the past six years, she has co-taught an interdisciplinary, cultural-immersion course in Honduras. Dr. Tremethick received a baccalaureate degree in nursing and a master’s degree in community college teaching at Northern Michigan University. She completed a PhD in community health at the University of Tennessee in Knoxville, TN and a post-doctoral fellowship in community health programming for older adults at Kansas State University in Manhattan, Kansas. She also holds a Master Certified Health Education Specialist Certification.

Eileen Smit, MSN, RN, FNP-BC
Email: esmit@nmu.edu

Ms. Smit is a professor in the School of Nursing at Northern Michigan University in Marquette, MI. She received a MSN degree in Psychiatric Nursing from the University of Wisconsin Madison, WI, and is a certified family nurse practitioner. For the past six years, she has co-taught an interdisciplinary, cultural-immersion course in Honduras.