May 14, 2010 — As a military kid, University of Virginia nursing student Madeleine Gawne discovered she could live anywhere in the United States and in Europe. Now she knows she could practice nursing in nearly any environment.

As her time in the School of Nursing wound down, Gawne sought to challenge herself with an international clinical rotation, especially in a country outside her comfort zone. In April, she began a monthlong stint on the Honduran island of Roatán, about 50 miles off its east coast, where a U.Va. faculty member and other University nursing students had established a relationship with a clinic.

The island is about 40 miles long and only a mile or two wide. The eastern half was originally settled by native Caribs, Africans abandoned from slave ships and slave exiles from the Caribbean island of St. Vincent. Hondurans later settled the western end of the island, and their Spanish language contrasts with the French/Spanish patois spoken by the "islanders," as they are known.

Gawne's high school Spanish was put to the test along with her nursing skills as she confronted a stew of cultural influences and racial tensions.

"I think the School of Nursing has spent a lot of time preparing us and discussing the importance of cultural competency, and learning how to be respectful of different cultures," Gawne said. "I am of the belief that it's difficult to be culturally competent unless you have put yourself in a position where you are in the minority and the outsider; to see what its like when the tables are turned." 

At the Clinica Esperanza, Gawne found certain familiar patterns of illness among the impoverished patients: high rates of hypertension, diabetes and obesity. Most food is imported from the mainland at a high cost; there are few available or affordable vegetables or fruits to provide a healthy diet. On an island with virtually no sanitation or clean water, it is cheaper for people to drink Coke than water.

But she also found other surprises. The island has had a hospital for only about 20 years, so there are not yet drug-resistant strains of infection and, since patients cannot afford much testing, there is high use of broad-spectrum antibiotics. Diabetes is almost exclusively treated with pills rather than with insulin, perhaps because of the complications of dealing with syringes and proper storage of insulin. With highly limited supplies, the clinic and neighboring hospital often operate on a barter system. Once, when the clinic exhausted its supply of normal saline, it traded two recently donated wheelchairs and a stretcher to the hospital to get the needed solution. Doctors prescribed medications as long as they were available; one of Gawne's tasks when she worked in the pharmacy was to let the doctors know what drugs were available that day.

With nearly 3,000 people living in about one square mile on a steep hillside, safe drinking water is seldom available and sanitation non-existent. Fresh water is hauled up the hillside only every eight days, resulting in many cases of children with severe diarrhea caused by water-borne diseases not typically seen in the U.S. 

With all these challenges, Gawne was especially impressed with the dedication and effectiveness of the team she worked with. The clinic was started 10 years ago by an American nurse and has two Honduran doctors, a visiting American doctor every few weeks, an registered nurse from the island and a Honduran office staff. Visiting nursing and medical students augment the staff and operating expenses are funded by donations.

She and the nurse practitioner created suture and suture removal kits for the doctors. "One of my favorite discoveries about nursing was that it takes inordinate amounts of creativity and engineering to get a job done with only the supplies in front of you," Gawne said.

Another discovery was the importance for well-meaning aid organizations to communicate with local health providers to build on existing resources and to engage community members who speak the language, know the culture and are more credible with the local people. Coordination helps to stretch resources, assures better sustainability for the facility, and improves continuity of care and outcomes for the patients.

"I felt very comfortable with my nursing skills on the floor, and knew that this could only make me a better, more sensitive nurse," Gawne said. "I had a wonderful group of faculty and staff to support me in leaving the country, and I knew that I had something to offer – it was just a matter of finding where I could be of the most use in that environment."

She said she feels satisfaction in knowing that she was able to make real contributions to the clinic's work. One project: creating booklets that patients can use to keep track of their blood pressure and blood sugars wherever they get them taken. "Consistency is a problem with this patient population because they go to our clinic, free clinics as they come, the hospital, etc.," she said.

She is also proud of her contributions to patient education and in expanding prenatal nutritional information to include maternal nutrition, so that mothers will be equipped to make the best decisions they can with their limited resources. She was pleased to see that in early June the clinic plans to open a pediatric care floor, labor and delivery rooms that accommodate families and other facilities. They recently received approval for a nursing school and hope to open those doors within another couple of years.

Looking back, she said, "I realize that coming down to Honduras was never about the great nursing skills experience so much as trying to make myself a more culturally competent nurse, and I feel like that is what I have done the most."

Soon, Gawne will become a neonatal intensive care nurse at Children's National Medical Center in Washington, D.C., but someday she hopes to have an experience similar to the one she had in Honduras. "This is one of the most humbling things I've ever done." she said.

"It's life-altering."