DEVELOPING A COMMUNITY NURSING SERVICE IN SOUTHERN LEBANON

Lebanon
Lebanon is country rich in hospitality, fruit and vegetables, water and scenery. It is also rich in paradoxes, inconsistencies, bureaucracy and inequalities. It is never boring. Any attempt to explain the culture of Lebanon would be futile. Everyone in Lebanon has his own explanation and each his own version of history.

Response International in Lebanon
Response International has been running programmes in southern Lebanon since 1996, just after Israeli jets bombed and killed civilian families taking shelter in the Fiji Battalion UN compound in Qana.
It first offered counselling to survivors. Then it introduced mobile clinics into nearby isolated areas, provided in-service training for health staff in villages and government hospitals and a number of other health-related projects.

Healthcare Provision
The underlying problem was that Lebanon has treatment-orientated, hospital-centred health provision. Doctors far outnumber nurses and those nurses have relatively low status in the minds of fellow professionals and the general public. Few practical nurses are formally trained. What trained nurses there are tend to be in large private hospitals in the capital, Beirut.

Meeting the challenge
The aim of Response International is to develop a community nursing service in southern Lebanon. The project is funded by the UK National Lottery Charities Board.

So how do you create such a service in a country where the concept is alien, where the government has no money to spare, and in an area where there are no professionally trained nurses? To top it all, there is resistance, on the part of some doctors, to anything perceived as threatening their income. Nurse-led health promotion, advice and monitoring means that fewer people need to consult the fee-charging doctors.

The management of the change process required a number of integrated strategies:

• Recruit and train our own group of nurses, in a discreet area of the country, to an agreed nationally accredited curriculum.
• Run a community nursing service led by ex-pat nurses to build the caseload and provide learning experiences for the nurses.
• Raise awareness of health issues through public meetings and targeted strategies.
• Train existing health care staff to monitor and advise those with chronic illnesses.
• Encourage local staff to institute health assessment from birth to school age.
• Introduce a community nursing module to selected nurse training schools with the approval of the Ministry of Public Health.

Recruitment and Training

Ideally we would have recruited up to 30 “trained” nurses and run a post-qualifying course in community nursing. But we had to deal with the reality that, in the whole of southern Lebanon, there were only around 10 nurses qualified to a standard approaching that required for registration in Europe.

So we designed a course, based on a syllabus acceptable to the Ministry of Public Health and developed a curriculum which we could deliver, part-time over two years, to a group of locally recruited students from the villages in the project area. Next came the problem of recruitment.

How do you attract recruits to a course when the status of nursing is low, there is no guaranteed employment at the end of the course, and few people have any idea of what a community nurse is? Because of 22 years of continued shelling, bombardment and other conflict, all the well educated people have left the area and those who stayed, especially the women, had to eke out a subsistence living growing tobacco, olives, fruit or small herds of sheep or cows. Education had received low priority in the scheme of things.

We held public meetings, giving teaching sessions on health issues, promoting discussion, inviting questions, getting to know the people. Thus we were able to give people a taster of learning about health, and, at the same time, assess the potential of those attending (mainly young women) to learn and apply that learning. Then we met their families to explain things to them and get some commitment that they wouldn’t keep them away from lectures and placements when the tobacco needed harvesting.

So then the course started, on two afternoons a week, in one of the village clinics. Then we were faced with other problems – shelling, weather, darkness and Ramadan. Shelling and bombardment were facts of daily life. These villages had experienced hostility for 22 years. Apart from the personal security situation, sitting in a classroom with shelling only a stone’s throw away was not exactly conducive to effective learning. We had to cancel lectures on several occasions. Even though Lebanon is blessed by warm weather, in the winter months the hill villages can get quite cold in the evenings and nights. There are oil fires, if there is sufficient fuel and someone remembers to light them in advance. Lebanon is subject to frequent electricity power cuts. Many lectures were conducted in the dark or by torchlight. The expensive overhead projector we had purchased was often idle and we had to improvise with a white board lit by lamps. On one occasion, I remember sitting in our Land Rover in the car park, trying to train the headlights on the board through the open door of the clinic.

Then came the holy month of Ramadan. Apart from two Christians, all of these students were Shiite Muslims. In Ramadan, Muslims fast during the hours of daylight (unless they are sick or menstruating or traveling long distances). This means that women get up at about 3.30 am to do the housework and prepare a meal before the sun rises. By the end of the day the students were very tired and we also had to rearrange times so that they did not coincide with Ifta (breakfast at nightfall)

Despite these very practical problems, we retained the full cohort and usually everyone turned up for lectures. Such was their commitment.
The next difficulty was to teach girls who had had little education. What learning they had had been by rote, as is the style in the Arab world. Asking questions, debating, syndicate work, researches were all alien. So it took much effort to get the students to participate in their own learning, especially in such things as psychology and communication studies. The culture does not encourage expression of inner feelings, the admission of psychological problems and needs. We used a Virginia Henderson model of nursing because, fortunately, that was prescribed in the national curriculum. But, initially, we had to adopt a fairly mechanical approach to the application of the model (“This problem suggests that goal and this intervention”….evaluation is always a sticking point, even in the UK). Gradually we got them to see that maybe it would be good for the patient if they were involved in their own goal setting.

However, another important thing had happened to allow hospital placements to happen at all. The Israelis and their militia had withdrawn from the large area of southern Lebanon which they had been occupying for over two decades. So the homes of the students now knew peace. Many of the students had yet to be born when the occupation and hostility had started. Moving about the area became easier and stress-free. Families were confident that is was safe for their daughters to travel down the mountain to the hospitals of Tyre on the coast.

In the hospitals, students were faced with a hospital system in which nurses only did things on the instructions of doctors. There was no nursing documentation or systematic approach to anything approaching a nursing process. So we had to create our own documentation and go through a whole change management process to get it used. Managing our own nurses in the community was one thing, but changing ingrained hospital practice was another kettle of fish. The situation was further complicated due to the fact that the government hospital is actually situated inside a Palestinian refugee camp.

One factor that was helpful was that several schools of nursing were using the same hospitals for placements. With so many students and their teachers all singing from a similar hymn sheet, it had to have an impact on the regular nurses and doctors in the hospitals.

We ran a structured staff development programme for hospital nurses in two Government Hospitals. Both of these hospitals, for some historical reason, were managed by the Lebanese Army with very little input from the Ministry of Public Health. In both cases, the officers in charge had no medical and little managerial experience. We introduced simple, one sheet, care plans. We bought screens for the beds so that patients could get some privacy and consequently could be examined comprehensively. We supplied sharps boxes and a big concrete sharps pit as part of an agreed sharps policy. We gave sessions to staff on control of infection. Gradually things improved (very gradually).
So now we were producing people close to what could be recognised as nurses. But we were still conforming to the hospital-centred idea of nursing. Our aim, after all, was to create community nurses. So the next step was to place one or two nurses at a time with our British community nurse working in the border villages.

The Community Nursing Service

By now, Response International was working in villages either side of the line that separated the Israeli occupied area from the rest of Lebanon. We cover quite a large area. One nurse and an interpreter go regularly to twelve villages on a fortnightly rotation and to other villages and at other times as the need arises. All types of problems are seen. There is a surprisingly high incidence of diabetes in the area. There are a number of contributing factors – lifestyle, diet, prolonged low-level stress, and poverty, poor education, easy cultivation of lots of sugar-rich fruits, delayed recognition of symptoms, diagnosis and management. To compound this there are the range of diabetic complications from hypertension and failing sight to ulcerated feet and hemiplegia, most of which can be prevented with a modicum of health education and regular monitoring.

Then there are the wounds of war – shelling, phosphor bombs, and the ever-lingering landmines. There are genetic abnormalities which are common to restricted gene pools of a population with limited mobility and to families where women bare children after children to late womanhood. And all this is topped by the ravages of chronic stress – not the much-quoted PTSD - but an insidious, chronic stress which eats away at even the hardiest.

Patients are seen in clinics and in their homes. A clinic is not always a purpose built building. It can just as easily be an impromptu gathering in a mosque hall, the muktar’s veranda, a school room or someone’s back garden. Where there is no local health worker, we try and get someone to volunteer to receive some basic training or at least take responsibility for contacting us to make a referral. We keep regular contact with all the local hospitals (public and private) and with clinics and other organisations which may wish to refer patients.

Using an interpreter has its benefits and pitfalls. Simple information and advice is easily translated. Helping with a psychological problem is very limited. So we trained a small group of local social workers in mental health issues. They are now able to provide short counselling, particularly in stress management. They are also able to make early referrals to specialist practitioners if required.

Health Education

Health education is central to community nursing, whether it is advice on diet to a diabetic, on stress management to an asthmatic or wound care to a mother of a mines victim. Wherever we go, we tend to gather a crowd. It may be other family members, friends, or just curious neighbours. Each of these gatherings is an opportunity to raise health issues, check blood pressures, answer questions and go through the plastic bags full of hoarded medicines. At first, people would only approach us if we had medicines to give to them. Over time, they have seen that we offer practical advice which can improve their health and quality of life without paying out for unnecessary medical consultations, examinations and medications. More formal gatherings are also held in public halls to cover a health topic and answer general questions. We have also initiated and run first aid classes and facilitated groups specifically for women’s health issues.

Training Existing Healthcare Staff

Most of the villages have at least one clinic, some two. These are not all government clinics. In fact the government clinics are in the minority. They are more likely to be run by a political faction or an NGO (non governmental organization). So in one village the clinics may be Red Cross, Amal, Hisbullah, Caritas, or one of a host of other small movements and community groups. These clinics are staffed by doctors on a sessional basis and by “nurses” who may or may not have received any training. Some are merely doorkeepers, other dispenses medications, and others may do simple dressings and give injections.

Over one year, Response International trained as many as 30 of these staff to a standard where they could make nursing assessments, give good health advice, monitor the chronic sick and refer when necessary. We laid out referral criteria for diabetics and asthmatics and persuaded local doctors to agree to these criteria and other protocols. These nurses are now able to complement the work of the doctors, rather than just follow their instruction. Response International supplied them with such things as glucometers, peak flow meters, and a battery of health education material in Arabic and pictures. They are also visited regularly to give them encouragement, iron out problems and update training. Many of these nurses are not paid, but volunteer their time. Not all venture out into people’s homes as yet, but will do so as their confidence and competence is developed.

Local Health Initiatives

The most successful way to get many local people involved in health was to train them in simple methods of school health surveillance. 15 schools were visited and arrangements made to assess the health and development of all four and five year olds. We instructed local nurses, teachers, community workers and some parents to do simple tests of eyesight, hearing, manual dexterity, verbal skills, memory, gross and small muscle coordination, height and weight against standard charts and general health. The Ministry of Education allocates each school to a particular faction in matters of health. So some schools are Amal and some Hisbullah. The Ministry had also supplied each school with health assessment and development forms. However, schools had been expected to employ doctors to do the assessments. None could afford to pay the doctors, so assessments had not been done. With a little instruction, the tests could now be done effectively by local people and appropriate use made of the findings. They could either refer to a medical practitioner or other specialist, or could make appropriate changes within the classroom to overcome any developmental or sensory deficit. Equipped with new skills, these local people can now repeat the process for each new intake of four and five year old, without supervision. They are also able to instruct people in other schools in the area.

As more nurses receive training, it is the aim of Response International that standard health and development tests are introduced for use at all stages of development from birth to school age.

The Introduction of a Community Nursing Module in Basic Nurse Training
Our own nurse training programmes were confined to a relatively small area of the country near to the hostile border with Israel. But without a general increase in the awareness of community nursing, this work could become marginalised and seen as an eccentricity of a British NGO.

To improve this general awareness, a Community Nursing module was written which could slot into nurse training programmes anywhere in the country. The most prestigious hospitals are the teaching hospitals of Beirut. What they do now, the rest of the country tries to emulate later. They are in the immediate view of ministers and civil servants. The chief nurse at the Ministry of Public Health also teaches in one of these hospitals. So when she was presented with the module, she took it, presented it to the training school, and within weeks it was a part of the curriculum. The plan now is to visit all the other schools and tell them what their competitor is offering, the benefits of having the module and how it can be assimilated into their own studies.

The module requires that students meet certain learning outcomes which can only be gained by practical community nursing experience. This again creates the tension for change and the movement towards a more widespread community nursing service.

Evaluation

Looking back over the years in which Response International has been in Lebanon, it is heartening to see the changes that have taken place as a result. However, there is still much to do. Response International continues its mission – to boldly go where no NGO has gone before (forgive me, fellow Trekkies). Now southern Lebanon is no longer a hostile area, the international donor money is gradually drying up. Whilst much of the infrastructure is in danger of slipping back or at least progressing no further, the villages around Tibnin now have access to quality nursing care provided by enthusiastic professionals who, with minimal support, can sustain a service well into the future.

David Vickers,
MSc (Nursing), BA Hons (Psychology), Cert Ed, RGN, RMN, RNT, CertTCMH
Nursing Coordinator, Response International, Lebanon (1999 – 2001)