Article Summary "FOR KIM WOODS ONLY"

n AONE delegation of 10 nurse leaders and 3 guests had an extraordinary experience in

Peru this fall. Our team was diverse and includ- ed point-of-care nurses in graduate school, nurse man- agers, a nurse director, academicians, and nurse executives.

HEALTH CARE IN PERU On our first day in Peru, we visited the Clinica Anglo Americana in Lima. We met with Morayma Custudio, director of nursing at the clinic, Veronica Ramos, subdi- rector, and Flor Vallejos, head of nurse security (quality management). This hospital and clinic represent the pri- vate sector of health care in Peru, 1 of 3 basic constructs based on insurance coverage. Public hospitals serve the uninsured, social security hospitals serve those with worker insurance, and private hospitals called clinicas pro- vide care to those who are privately insured. The public sector is open to anyone without insurance, covering approximately 50% of the population. The uninsured receive basic health care, which is covered through taxes paid by citizens of Peru. The social security hospitals and clinics provide care for any citizen who receives a pay- check, representing about 40% of the population, but special hospitals provide care for the police and the mili- tary. Those with worker insurance have money deducted from their paychecks to cover health care. Lastly, private hospitals provide care to approximately 10% of the popu- lation, including a small segment of workers with private supplemental insurance.

The Clinica Anglo Americana was one of the first in Peru to receive Joint Commission International accredi- tation, and it is on the journey to receive Magnet® desig- nation. The nurse leaders we met there were very passionate about their work, using a “patient first” philos- ophy developed at the Cleveland Clinic and a practice model based on Jean Watson’s Theory of Human Caring.1

On touring the hospital, we saw a very busy emergency department (ED). ED staff see approximately 70,000 visits annually. The hospital itself has only 91 inpatient beds, including 10 ICU beds and 10 pediatric beds. The ED

wait time can be up to 2 hours in the private hospital, and waits in public hospitals can be 6 days or longer. It is com- mon for patients to wait up to 6 months to gain access to care. Only 3 mental health facilities are in operation and all located in Lima—so rural residents would have to travel for this care. Peru also doesn’t have advanced practice reg- istered nurses, who have proven essential in broadening access to care in the United States.

The nurses generally work 12-hour shifts, with salaries in public hospitals ranging from $300 to $500 for 150 hours per month and $750 to $1,000 per month in pri- vate hospitals for the same hours. However, a limited number of these jobs exist, so it is hard to gain a full-time position. Most nurses work 2 full-time jobs to earn a living wage. And the turnover of nurses can be upwards of 50% due to the challenges with the workload and work environment. Leaders at Clinica Anglo Americana appointed a chief nursing officer (CNO) for the first time this year, equal to other leaders in the organization. The use of a CNO is relatively new in Peru; in 2013, Clinica Santa Isabel, a maternity hospital, was the first organiza- tion to appoint a CNO. At Clinica Anglo Americana, leaders are making big strides in the professional practice of nursing in the private sector, but they are experiencing challenges. Although the organization has strong leaders advocating for evidence-based practice in structure and processes, it did not appear to have a robust formal lead- ership development program for nurses and nurse leaders.

During the week, we also visited a remote indigenous rural clinic, the Ollantaytambo Medical Center, serving the medically underserved. This small clinic had very limited resources. Staff primarily provide maternal care, delivering up to 10 babies per month. Elective inductions and c-sections are not available, and the clinic does not provide many pharmaceutical interventions. Staff ’s biggest health concern is post-partum hemorrhage, similar to the United States. They were also concerned about anemia due to poor diets.

Reflecting on our visits to health care providers, delegation member Carol Watson, PhD, RN, discussed a

A

AONE Delegation Learns Challenges, Successes of Peruvian Nurse Leaders

Bob Dent, DNP, RN, CENP, FAAN

www.nurseleader.com Nurse Leader 371

372 Nurse Leader December 2018

“doing better with less” philosophy. This is different than “doing more with less.” In today’s tumultuous health care environment, we sometimes find a need to “do better” with the resources we have in meet- ing the cost, quality, and access issues nurse leaders face regularly.

We also visited with faculty of the school of nursing at Universidad Norbert Wiener, a private higher educa- tion institution in Lima where Patrick Palmieri, DHSc, MSN, ACNP, FAAN, is the Margaret Jean Watson dis- tinguished professor and dean for the school. Prior to returning to academia in 2014, he led a team that devel- oped the largest vertically integrated private health system in Peru, called SANNA. The school of nursing is globalizing and advancing the nursing profession through its work to earn the first international accredi- tation in Latin America for a school of nursing with the Canadian Association of Schools of Nursing. The final site visit is scheduled for October 2019.

At the school of nursing, we formed a circle with our delegation and the faculty to have a dialogue about nursing and nursing education. Many students attended and joined the conversation. The faculty consisted of nurses with graduate degrees, many of them working to complete their doctorate degrees. During these conversations, we learned the nurse-to- patient ratio in the medical/surgical environment in public hospitals is up to 30 patients to 1 nurse (and 5 to 1 in private hospitals). A nurse may have the help of 1 nursing assistant. In the surgical area, the ratio is

14:1, in critical care units, 2:1. To manage these staff challenges, the nurses ask families to be at the bedside to assist with providing basic care for their loved ones. Faculty added they did not have robust data collection on patient outcomes, largely monitoring for adverse outcomes.

Nursing students from Universidad Norbert Wiener receive training at Lima’s Hospital Nacional Edgardo Rebagliati Martins, a social security facility. Established in the 1950s, the hospital has 1,600 beds and employs more than 1,000 nurses. Prospective nurses have 2 primary ways to enter the field. A 3- year, technical nurse degree, similar to the LPN, can be earned. These nurses can delegate tasks to the nurs- ing assistants. The other way involves a 5-year nursing degree, similar to a bachelor’s degree, with a research thesis. For post-graduate work, nurses can earn a 1.5- year specialization, a master’s degree, and a doctoral degree in nursing. The faculty and nursing students voiced a desire to create stronger relationships and collaborate with nurse leader colleagues around the world. They wanted to know the ways in which AONE and other organizations in the US nursing community were reaching out to them. We discussed opportunities to collaborate with AONE on nurse leader development, using the AONE competencies as a foundation. Here, too, faculty noted that nurse lead- ership development was lacking in their environments. At the end of the discussion, the students were asked, “Why do you want to become a nurse?” Their

The AONE delegation visited the 91-bed Anglo Americana Clinica in Lima, Peru, a facility in the process of earning a Magnet designation.

Nurse Leader 373www.nurseleader.com

answers were the same as we often hear from US nursing students—to take care of patients and improve health care in the communities they serve.

We met with professional nurses from the Colegio de Enfermeros del Peru, the Peruvian College of Nursing, perhaps equivalent to the National Council of the State Boards of Nursing combined with the American Nursing Association in the United States. The organization’s role is to strengthen the profes- sional practice of nursing, along with a social and legal responsibility to prioritize the development of com- petencies of the local nurses and nurse administrators. Peru has 28 regions, each with an organization similar to US state boards of nursing, reporting to this central body. Nine elected members serve on the national board, which acts to defend nurses against unjustified hospitals complaints and maintain the ethical standards for the profession. In Peru, approximately 1.5 nurses are available for every 1,000 people, whereas the United States has 11.2 nurses for every 1,000 people (compared with 0.5 physicians for every 1,000 in Peru and 1.1 per 1,000 in the United States). Similar to the United States, 10% of nurses are men. The nurses explained how last year the Colegio Médico del Perú (Peruvian College of Medicine) attempted to imple- ment a national law to prohibit nurses from holding leadership positions in large public hospitals. Representatives from the College of Nursing also noted at the local point of care the physician/nurse relationship is more collegial than at the national level.

LEARNING ABOUT HEALTH NEEDS We had the opportunity to visit a primary school in a rural area with children ages 3 to 6 years. The teachers are very compassionate and seem to love their work, with some serving at the school for 25 years. The students sang to us, played with us, and gave us big hugs. It was an emotional visit for some in the delega- tion. Although the students had few resources, they had great attitudes, big smiles, and even bigger hearts. When the teaching staff was asked about students’ health care needs, 3 big concerns surfaced: dental care, parasites, and anemia. Earlier in the week, Palmieri noted Peru has a national campaign to eliminate ane- mia, as this is a serious health problem. The first nurse to become a minister in Peru, Liliana La Rosa, was appointed this year and is working to eliminate this major problem.

TAKING IN THE CULTURE When not gaining insights about health care, we learned about Peruvian culture and history. For

instance, Palmieri explained that a kiss on the cheek is a fundamental custom for greeting friends and colleagues, and it helps support relationships. He learned this les- son shortly after he arrived in Peru some 10 years ago, when he was scolded at work for neglecting the cus- tom. Because relationship management is an important competency for nurse leaders, our group paid attention!

We had opportunities to enjoy many Peruvian sites, including the Larco Museum, the Sacred Valley, Pisac Market, Cusco, and Machu Picchu. On the last day, we had a private guided tour of the Casa Concha House, learning about the rise and fall of the Incan empire with anthropologist Jean-Jacques Decoster, PhD. Decoster mentioned the Inca’s engineering techniques were remarkable in adapting to their envi- ronment. He stated, “Culture is a people’s adaptation to an environment.” I asked him if this could be relat- ed to settings where professional nurses practice. He confirmed that yes, nurses would adapt to the envi- ronment created. This brought to mind the nurses I had seen in various environments on our trip, skillful- ly using resources to provide compassionate care. It also reminded me of the some nurse workplaces in the United States. Are we creating positive and healthy workplace environments?

AONE delegation member Joan Osborne, EdD, MSN, ARNP, hugs a new friend during a visit to a rural Peruvian primary school.

374 Nurse Leader December 2018

Reflecting on my experience, here are steps nurses can take to reach out to their international colleagues, virtually kissing them on the cheek:

• Disseminate research and evidence-based prac- tices in venues and publications accessible to our international colleagues. Consider copresenting with an international colleague.

• Consider having a sister facility in another coun- try. Collaborate with nurses there to improve nursing practices.

• Help to bridge the gap between innovation (research) and nursing practice with our profes- sional colleagues globally.

• Create positive and healthy workplace environ- ments where nurses can adapt, creating a culture where nurses and their interprofessional colleagues can “do better with less” to improve global health.

We had an experience of a lifetime in Peru. This article and the thousands of pictures taken by the team cannot express the emotions felt nor depth of the experiences we had on our weeklong excursion. The people were welcoming, and the food was deli- cious. Our experience also showed a hunger from

those we met to continue the conversation beyond this journey. I hope the discoveries we made in Peru will inform our work as nurse leaders, making the best use of resources and striving to make a difference for patients and each other. NL

Reference 1. Watson Caring Science Institute. Core concepts of Jean Watson’s

Theory of Human Caring Science. 2010. Available at: https://www.watsoncaringscience.org/files/PDF/watsons-theory-of- human-caring-core-concepts-and-evolution-to-caritas-processes- handout.pdf. Accessed October 24, 2018.

Bob Dent, DNP, RN, CENP, FAAN, is 2018 president of the AONE Board of Directors. He is senior vice president, chief operating and chief nursing officer at Midland Memorial Hospital in Midland, Texas. He can be reached at [email protected].

1541-4612/2018/ $ See front matter Copyright 2018 American Organization of Nurse Executives. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2018.10.006

The AONE delegation took in the scenery of Machu Picchu, a 15th century Inca citadel.