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1 Disclosre presenter

2 2 Introdcing the Family Nrse Practitioner Role in Haiti: A case stdy ANDRÉA SONENBERG, PHD, WHNP, CNM-BC, FNYAM, FNAP CAROL F. ROYE, EDD, RN, CPNP, FAAN

3 Introdction 3 Haitian people have the worst health in the Western Hemisphere. Highest maternal/infant mortality ratio & cervical cancer deaths Most Haitians do not have access to care Most of those who have access receive care from a nrse; however, Haitian nrses are not edcated to provide primary care An existing resorce of ~1,400 qalified Haitian nrses who can be edcated to become family nrse practitioners (FNPs). (Sorce:

4 Promoting Health in Haiti (PHH) 4 «I think one s feelings waste themselves in words; they oght all to be distilled into actions which bring reslts.» Florence Nightingale A Non-Governmental Organization (NGO), fonded by American and Haitian- American nrses, is edcating Haitian nrses to obtain a Master s Degree as FNPs, who will be skilled to practice throghot the contry Each providing care to ~20 people/day for p to 5,200 visits/year. 34 have been edcated. They have already gradated and are providing critically needed care.

5 Health Workforce in Haiti 5 To achieve SDGs, WHO recommends that the workforce capacity mst maintain 4.45 health care providers (doctors, nrses and midwives) per 1,000 poplation (WHO, 2016). With Haiti s poplation being greater than 10.9 million, it is one of five contries in the Americas facing an extreme pacity of each of these grops of health workers Only 0.65 doctors, nrses, and midwives per 1,000 people (USAID, 2017). Frther complicating the state of health workforce in Haiti is the fact that the Ministry of Health does not have crrent and accrate data (Ibid). The last entry on the WHO Global Observatory for health workforce in Haiti is 1998 (WHO, 2015).

6 Family Nrse Practitioners 6 In the US, nrse practitioners (NPs) provide a higher proportion of care to nderserved poplations than physicians (Van Vleet & Paradise, 2015). NP care is of comparable or higher qality than medical care for a variety of health conditions (Lenz, et al., 2004; Newhose, 2011). Haitian nrses are edcated at approximately the Associate Degree level. They receive a diploma on gradating. For them to become edcated as FNPs, they wold need to have had a Bachelors degree preparation to obtain their nrsing degrees.

7 A Soltion-Promoting Health in Haiti 7 After the 2010 earthqake, a grop of faclty from CUNY went to Haiti to assess the health needs. They fonded PHH and did a health needs-assessment PHH set ot to implement a Master s Degree program for FNPs. Wanted to begin the program in the pblic sector While waiting for MOU to be signed, began in an established school, Faclté Sciences Infirmières de Leogane (FSIL), whose gradates had a Baccalareate. The PHH faclty: the PHH exective board who teach at Pace University, College of Health Professions, Colmbia University School of Nrsing and Nassa Commnity College. Volnteer and travel to Haiti to teach Figre 1. Theoretical Model: A Cltral Framework for the introdction of new health care delivery (Sonenberg, 2013)

8 The Intent of the Stdy 8 Ø To explore the process throgh which the first FNP edcational program was introdced by PHH to this low-resorce contry, in the aftermath of a natral disaster. Ø Significance: Identifying myriad factors and steps in the process in Haiti cold inform sstainability and scalability to other low-resorce contries needing to improve access to care.

9 Methods: The Design 9 Qalitative Exploratory Case Stdy Signing the MOU Sample: Prposefl sample: 4 participants, of whom three were Haitian (and French speaking) and one was Haitian-American. All interviewees were stakeholders and collaborators involved in the vision and development of the PHH initiative to edcate FNPs and introdce the FNP role to Haiti.

10 Methods: Procedres 10 IRB approval obtained Interviews: Informed consent Focsed interview qestions; probing qestions spplemented the interview. Taped-interviews were condcted in French or English. Haitian partners: the Chancellor of the University of Haiti, the former Head of Gradate Programs, the Director of Nrsing at the Ministry of Health Haitian American partner: the Vice-President of PHH, who is Haitian- American. Condcted in Haiti; recorded and transcribed. French transcriptions were sent to the interviewees for confirmation of accracy. Confirmed French transcripts professionally translated into English.

11 Methods: Data Analysis 11 Embedded Analysis Thematic Coding English transcripts were individally & separately analyzed by each of the two co-investigators. Pre-determined and emergent themes were explored Completed member-checks with the interviewees Co-investigators compared their thematic analyses & coding to confirm a common analysis insights into the facilitators, barriers, and process in establishing partnerships for improving edcation & health.

12 Themes: Overall qality health 12 (CB):, we were very concerned that the poplation and the people were not receiving adeqate care becase they were sitting in the commnity. (NS): Always the same concern. Conditions were never good. They were always conditions were difficlt. And speaking abot health care, this is a really serios problem here in Haiti. (IB): So far, yo know that health conditions, health care in Haiti are very precarios sometimes we have very difficlt sitations.

13 Theme: System-Workforce 13 Nrses Majority of the workforce Level of edcation (not qality/not adeqate) Practice: Not trained for some of the care they were giving Doing Medical Fnctions Inadeqate remneration to meet needsà holding 2-3 jobs Doctors Do not stay in Haiti (Not in hospital bedside)

14 System: Workforce - Nrses Inadeqate workforce capacity Lower level of edcation 14 (CB): And they don t have enogh doctors to take care of them in the hospital, that s one. evening and night, the nrses will tell yo they have never seen a doctor, they are there, they are the ones... (RH): nrses shold also evolve as a professional, instead of staying at the technical level. They shold go beyond that by reaching master, and even PhD level They really take care of the sick. (NS): In general, nrses are those responsible for providing health care in Haiti, in hospitals and in health centers. Bt we mst also recognize that these nrses did not receive maybe convenient training, since they jst passed the baccalareate, the license So this is to say that the conditions were not optimm.

15 System: Workforce - Nrses Poor conditions & Underpaid 15 (IB): I have nrses who are working, who are, even thogh alone, are looking after health instittions They work in very difficlt sitations. Most often: work overload, lack of material to work with and wold like to tell the following with a more diplomatic way: with a minimm wage that does not really meet the needs. Sometimes the person is obliged to have two or three jobs to cover the needs and I think that we mst have a staff remneration policy. It cannot contine like this. (RH): and the people who work in health care too, I am speaking abot nrses, they are generally not well paid, becase here the compensation depends on the academic level. If yo are at a techniqe level, yo are paid a salary, yo get a salary, bt if yo are at an niversity level, yo have a salary, if yo have a master yo have an even higher salary and with a PhD, the salary is even higher, which means that whatever the level, the experience of a nrse, she will always be a nrse nless she has an administrative position. Therefore, concerning salary, they are leveled. There is an amont of salary that they cannot get. They sometimes need to work in many hospitals in order to get a medim salary.

16 System: Workforce - Doctors 16 (CB) doctors, they are no longer at the hospital. They are very few of them and the patients, they are not in the commnity They are edcated in the medical school and attend to find an opportnity to go to a private instittion or to another contry; they leave. So, when they leave, they left the nrses who were trained to assist them by the bedside. (RH) conditions were very difficlt in hospitals, and already in the contry there were many doctors who do not stay in Porta-Prince. And in general, in hospitals, it is rather the nrses who care for the sick

17 Theme: System - Environment System & Physical (Infrastrctre/Resorces) 17 (NS) Conditions were never good conditions were difficlt this is a really serios problem here in Haiti. (IB) They work in very difficlt sitations. Most often: work overload, lack of material to work with... (RHV) conditions were very difficlt in hospitals conditions which are not generally adeqate

18 18 (CB) The other thing, they did not have money. Becase when people are sick in Haiti, when they go to see a doctor or to a hospital, they are... after the examination, they give them a prescription. If they need intravenos, they mst go otside to get the intravenos.. The hospitals, they give yo nothing they do not have a pharmacy, they do not have intravenos soltions, and they do not have dressings or any eqipment. The only thing they give yo is the bed, and they may have an IV pole, bt they do not have anything else to give the patients.

19 Theme: Obstacles/Barriers 19 Resistance/Lack of trst Reglatory jrisdictions Lack of resorces Space/Home Qality Edcators Financial resorces

20 Theme: Obstacles & Barriers Resistance/Lack of trst 20 (CB): They think that I mst have collected money to do the project in Haiti that is where the trst problem is, they expect me to come and give them the money or share the money with them. Haiti has been an NGO ized, it s the contry of NGOs. NGOs have really collected money to do projects in Haiti. And after-while NGO leave, and NGO never really trn to people to contine to work...leaves the problem the project dies. So, really, they have seen that happened for centries. So, who the hell am I to come here and then it is jst another NGO, so yo know, that is part of the trst too.

21 Theme: Obstacles & Barriers Reglatory Jrisdiction 21 (IB) The Department of Training has no reglating laws... And between the Department of Training and the State University, it is the Direction of Nrsing care who is legally the one in relation both with the UEH and between the Ministry and the UEH (NS) there are always obstacles in all new projects that yo ndertake. There were expected obstacles... This is the instittionalization of the program to make sre that health and academic instittions will accept the program. it was not easy and it is still not easy,

22 Theme: Obstacles & Barriers Reglatory Jrisdiction (Cont d) 22 (RH): when there is no doctor, they are alone, they are alone - sally they are women - and they are alone with patients. They mst provide care; they sometimes also have to prescribe. And in principle, they do not have the right to prescribe, bt they are obliged to do so becase they know the symptoms, the problems, and there is no doctor... The fact that they do not have that right is also a concern. When there is something to be done, and there is no one to do it, they do it, bt legally they do not have formally that right.

23 Theme: Obstacles & Barriers Lack of resorces 23 Space/Home (IB): What was difficlt was to be able to find a space, in order to lay this program at the niversity level, becase we had to lg arond... It was difficlt to find space for the classes. And PHH offered to help s and gave s sch space for the Masters with several options (RH): Well, what I said initially as difficlties for the project was the logistics, the office where we can start the program, becase it was after the earthqake and then I was also concerned that we did not have teachers. The main concern was really the space where we cold work and financial resorces. and [PHH] has done everything possible to provide an office.

24 Theme: Obstacles & Barriers Lack of resorces (Cont d) 24 Qality edcator (RH): When the project came, we welcomed the project becase it was something that we were already interested in. We already thoght abot this program bt we had not yet the means to do this program: it needs teachers with good level to teach and also financial resorces, the financing. It means that the program was welcome to s at the University of State. Financial resorces (NS): Yes, the fnds reqired to make it work. Well, as this is a ministry program, we are in a pblic sphere, and it is very difficlt to discss abot money as if we were in a private sphere. Bt I think that we mst rely on beneficiaries. The program shold be based on the financial contribtion from the beneficiaries.

25 25 Themes: Facilitators The Will Trst Stakeholders/Collaboration PHH (NGO) MOH (Government)/ Insider(s) University (Edcation)

26 Themes: Facilitators 26 The Will (NS): I expected that if Dr. Bellefler was tenacios, eventally it wold pass. Indeed, thanks to her tenacity, it has passed. If we had the collaboration of some people in the system, it wold also pass. With Irma Bois, this was the case... Trst (CB): Becase I stay all this time and becase of what we have done, we are beginning to develop the trst. And actally becase of what we have done to prchase a bilding to hose the program, I think they have some respect for that.

27 Facilitators (Cont d) 27 Stakeholders/Collaboration (NS): So we expected that people will be facilitators, their dynamics, bt now we are experiencing it... So far, these are the stakeholders: PHH as the promoter and the University as a partnership assistant, which hosts the training and shares in issing diplomas, etc.; and the Ministry of Pblic Health throgh the Nrsing Care Department, which looks after the accommodation, the recriting, etc.

28 Facilitators (Cont d) 28 Resorces PHH Qality Edcators à credibility Space Resorces Ministry of Health Clinical Resorces (for school) University of Haiti Staff (school) Private Contribtions

29 Themes: Process 29 PHH establishment Sstainability (CB): To make this sstainable, we are planning to take two stdents to the US to go to a doctorate level. Those nrses will become nrse-scientist, they will complete the doctorate program, and they will retrn to Haiti to take over, to take charge of the program... (IB): First, acqire the workforce for the home. Always contine to work with PHH and with any other organization that wold provide assistance to establish the Master After that, we mst assme the sstainability of the program have a plan to permanently transfer this program between PHH and [inadible 0:11:24] I think PHH has a 10-year period

30 Process: PHH (Cont d) 30 Evalation Scalability to other lowresorce contries

31 31 Discssion & Implications This stdy delved into the work of Promoting Health in Haiti and confirms a striking trth. It is not possible to go into a foreign contry, even with all the right intentions, and create change. Change mst come from the people, themselves, who: live in the contry, know its cltre and langage, & best nderstand the difficlties & how to overcome them. The problems with health care in Haiti were, and still are, massive. Nrses, who are the mainstay of health care in a contry sch as Haiti, have no stats and are paid very little. They have to work 2-3 jobs jst to make ends meet. They have no respect.

32 32 Discssion (Cont d) After the needs assessment, the first task of those determined to intervene was to develop trst with the stakeholders, and then with the stdents. Withot trst, PHH wold have been viewed as jst another NGO coming to help in the frantic days after the earthqake. So many came, so few stayed. It took PHH s persistence to get as far as they have, and trst has fostered the sstainability.

33 33 Conclsion The process of introdcing a new health care role and model of care to an existing health care system in a low-resorce contry is complex. It is not a linear process, bt one that has mltiple steps, at times occrring simltaneosly and often inter-dependent, one on another. In an emergency sitation, sch as post-natral disaster, there may not be time to implement a defined framework sch as PEPPA. Trst and The Will, of both the interventionists and the inter-sectoral stakeholders, are integral to the sccess and sstainability of any initiative. Scalability depends on ongoing evalation and sstainable trst and resorces, shared among all collaborators. Addressing access to care and health globally is not beyond reach. Working within a collaborative, cltrally competent framework is the fondational pillar to the process.

34 References 34 Garfield, R. & Berryman, E. (2012). Nrsing and nrsing edcation in Haiti. Nrsing Otlook, Vol. 60/No 1, pp GHESKIO Centers (2013). Cervical cancer. Retrieved from Lenz, E. R., Mndinger, M. O., Kane, R. L., Hopkins, S. C., & Lin, S. X. (2004). Primary care otcomes in patients treated by nrse practitioners or physicians: two-year follow-p. Medical Care Research And Review: MCRR, 61(3), Newhose, et al., (2011). Advanced Practice Nrse Otcomes : A Systematic Review. Nrsing Economics, Vol. 29/No. 5, pp Sonenberg, A. (Jne 2013). A Cltral Framework for the Introdction of New Health Care Delivery Models. Seminar Electronic Annals of the 17 th Annal Brazilian National Nrsing Research Seminar. United Nations Development Program. (2015) Hman Development Reports. Retrieved from United Nations Development Program. (2015). UNFPA Urges Action to Meet Global Shortfalls in Health Workers. Retrieved from rate United States Agency for International Development. (2016). Haiti health workforce data adits lead to hman resorces for health improvements. Retrieved from file:///c:/users/asonenberg/downloads/haiti-health-workforce-data-adits-lead-to-hman-resorces-for-health- Improvements-FINAL%20(1).pdf Van Vleet, A. & Paradise, J. (2015). Tapping Nrse Practitioners to Meet Rising Demand for Primary Care. Retrieved from World Health Organization. (2015). Global Health Observatory (GHO) Data. Retrieved from World Health Organization. (2015). Global Health Observatory Contry Views: Haiti statistics smmary ( present). Retrieved from World Health Organization. (2016). Health workforce reqirements for niversal health coverage and the sstainable development goals. Retrieved from

35 35 Thank yo for yor attention!