Today’s Travel Nurse

Travel nursing, anyone?

If you’ve been working as a nurse for more than a minute, chances are you’ve heard the term travel nurse or worked with one. But while you may be aware of travel nursing, you may be uncertain about the pay, lifestyle, and how to go about becoming a travel nurse. This article looks at the current state of travel nursing and describes how to enter this adventurous side of nursing.

A travel nurse (commonly called a traveler) is someone who takes temporary nursing work or assignments lasting from 4 weeks to 6 months or even more. The most common duration is 13 weeks. These assignments may be local or hundreds or even thousand of miles from your home. You choose the location where you want to work and are obligated only for the term of your contract. Many travelers extend their contracts if they like the location and the facility has a continuing need for them.

The company you keep

To obtain a travel contract, most nurses work through a travel nursing company. Although you could contract independently with a hospital, I always recommend using a travel company for at least a few assignments to familiarize yourself with the process.

Most travel companies offer:

  • free private housing in the location where you’ll be working; depending on the specific company, this may mean a furnished one-bedroom apartment
  • travel reimbursement to and from the assignment
  • medical and dental insurance; many companies have several coverage levels, including coverage for spouses and family members
  • license reimbursement; unless you live in a state with a compact license, you must have a license in each state where you work.

Some travel companies even have 401K plans. Of course, you also earn a living, making a certain hourly rate as you would in any other job. Rates can vary dramatically depending on your nursing specialty, geographic region, and current demand for nurses.

Some people think of travel nursing as a “cash cow” that provides thousands of dollars in completion bonuses and offers pay rates better than those of staff nurses. While you can earn a fair wage as a traveler, travel nursing these days is more about the adventure than making a ton of money.

Don’t get me wrong. Some assignments pay quite well, and even today you could earn more than $100K as a travel nurse. But this would likely entail working in a high-demand part of the country in a job that guarantees 48- or 60-hour workweeks. You’re simply not going to make a ton of money working three 12-hour shifts a week in Hawaii.

Adventures on the road

For me, travel nursing has always been about the adventure. My first assignment was in Hawaii, where in 3 months I went from no experience underwater to earning my certification in SCUBA diving. I also took flying lessons in Santa Monica, rock climbing and rapelling courses in Phoenix, and improvisation and acting classes in Los Angeles. And I completed enough jumps in San Diego to skydive solo.

I’ve hiked over an active volcano in Hawaii and explored the insides of ships sitting 100 feet below the ocean surface in the Florida Keys. I’ve taken amazing sunrise photos of the red rocks of the Grand Canyon peaking through a blanket of newly fallen snow. I owe all of these experiences to more than a decade and a half in travel nursing.

Are you cut out for traveling?

Now that I’ve highlighted the fun aspects of travel nursing, you might be wondering, “What’s the catch?” While there’s nothing nefarious about travel nursing, it does require a certain type of person—one with an outgoing personality and the ability to adapt to and assimilate quickly in new environments.

Travel companies used to require their hires to have at least 1 year of nursing experience. But in 2009, that mandate took a turn. Various websites reported a sharp decline in the number of traveler positions for that year because of the troubled economy; one site put the decline at 44%. Like any career sector that has cut its available positions by almost half, the healthcare industry responded by demanding nurses have more experience before they can be hired as travelers. While some travel companies still claim you need just 1 year of experience, many have raised their requirement to 2 years of recent nursing experience. Nurses in higher-acuity positions that require additional training, such as critical care, may be able to get an assignment at the 18-month mark. But generally, nurses who are most likely to land a first travel assignment have at least 2 years of experience.

Also, if you plan to travel for an extended time and want to work in a higher-acuity area, get that experience before embarking on a travel career. As a traveler, you’ll have little to no opportunity to cross-train, because facilities are looking for nurses to staff areas where they have a need. Travelers are temporary employees, and facilities simply won’t expend the resources needed to cross-train a nurse who may be at their facility for just 13 weeks.

Travelers also should be comfortable in their skills and overall nursing practice. If you can’t start your own I.V. lines and still have trouble prioritizing your nursing care, “the road” is not the place to learn these skills. To meet the challenges of travel nursing, you must be proficient in your specialty. Adaptability is another key trait of the travel nurse. (See Adaptability counts.)

Orientation and testing

Being a traveler is like starting a new job every 3 months or so. On most assignments, you’ll go through orientation (often alongside the facility’s new staff hires), plus work a shift or two with a preceptor on the unit. But you should be prepared even if the facility provides little to no orientation (although this isn’t the norm).

Anticipate being tested during orientation. If you work in an area with cardiac monitoring, expect to take an electrocardiogram rhythm strip test. If you work in critical care, expect to be tested on relevant knowledge, most likely including advanced cardiac life support components.
In addition to written tests, you’ll need to prove yourself at the start of each new assignment. At most facilities, you won’t be the first traveler on your unit. But occasionally, you may enter tight-knit areas where you must quickly gain a reputation for being “that helpful new traveler.”

Socializing while on the road

In most cases, travelers work on units that are inviting and friendly. In many of the facilities where I worked, I spent most of my days off with someone from my unit. But I’ve also worked on units where I never saw another staff member outside the facility.

While being outgoing in the workplace is a key trait of the travel nurse, being an extrovert in your life outside the hospital is important, too. What fun would travel nursing be without the adventures you experience outside of work? Life on the road can be lonely without support or interaction with others on your days off. Many of my experiences as a traveler were solo pursuits or instances where I joined a group of strangers. But if you extend yourself even a little, many group situations will welcome you, especially if you share a common bond from the get-go. I did this by joining groups on SCUBA diving outings.

In this article, I’ve provided a highly condensed account of what it takes to be a travel nurse—but I hope it’s enough to give you an idea of the traveler’s lifestyle. I enjoy helping nurses get started in traveling, so if you have questions or need more direction, feel free to contact me directly at david@travelnursesbible.com.

David Morrison is the author of The Travel Nurse’s Bible: A Guide to Everything on Travel Nursing. He answers questions on traveling in his column “Ask a Travel Nurse” at http://travelnursingblogs.com/ask-a-travel-nurse.

Achieving a work-life balance

Almost everyone agrees that achieving a work-life balance is a good thing. Without it, we risk long-term negative effects on our physical and mental health, our relationships, and our work performance. But many nurses have a hard time achieving this balance due to job demands, erratic work schedules, or inability to say no when someone asks for help. Continue reading »

The joys of travel nursing

Editor’s note: Welcome to this special section on travel nursing. Whether you are currently a travel nurse or simply want to learn more about this rewarding specialty, these articles are for you! Start by getting an overview of travel nursing from expert Franklin Shaffer, EdD, RN, FAAN. Next, read about how you can continue your education online as you travel. Wrap up with an article on how to cope with those difficult people you meet along the way, no matter where you work.

What are the main benefits of travel nursing?

Shaffer: Travel nursing offers adventure, freedom of choice, and flexibility. Travel nurses can choose their work location and hospital, and they get a chance to work in exotic locations at prestigious medical centers. This freedom of choice is important today, with more people citing quality of life as their top priority. To a large degree, travel nurses control their own schedules. Recent interviews found that many of them had more than 15 years of continuous experience as travelers and planned to continue traveling for some time to come.

Also, many travel nursing companies (or staffing firms, as they’re officially called) offer higher salaries and a rich array of benefits; some offer access to continuing and higher education as well as certification. One of the larger firms even created a corporate university and is an accredited provider of continuing education for nurses.

Do travel nurses get to choose the exact location of their work and their exact work schedule?

Shaffer: Travel nurses decide where they work and when they will begin working at a particular facility—depending, of course, on availability of positions and shifts. The beauty of being a traveler is that you can shop around until you get the position and location you want. Having this autonomy and control over your schedule is a leading reason why nurses decide to become travelers. As for the daily staffing schedule, much of the traveler’s assignment, including days off, is worked out before the nurse accepts the assignment. Special schedule requests also are agreed to in advance. Typically, special needs that arise are worked out on a mutual basis by the traveler and the nurse manager at the facility.

Do travel nursing companies offer typical benefits, such as health insurance and 401K plans?

Shaffer: Nearly all nurse staffing firms offer a full array of benefits, including health, life, and liability insurance; 401K plans; dental insurance; and preventive care. Also, the staffing firm pays the nurse’s licensure and housing costs. Frequently, these benefits are effective on the first day of employment.

What’s the typical educational background of a travel nurse?

Shaffer: Travel nurses are likely to have BSNs or higher degrees and are more likely to be certified. A recent survey by a large staffing firm showed that 60% of their nurses had BSNs; this is above the national average. So travel nurses and other nurses working in temporary positions are just as qualified—and in some cases more qualified—than permanent staff nurses. Also, patient outcomes in hospitals that use temporary nurses have been found to be positive.

Why would a hospital want to hire a travel nurse?

Shaffer: For hospitals, travel nurses offer more flexible staffing and options that can be customized to meet their unique staffing needs in a cost-effective manner. Many hospitals have discovered that well-planned use of staffing companies is the secret to retaining nurses and, in turn, promoting patient safety. Some hospitals even use travel nurses as a way to recruit core nurses. A “try it, you might like it” approach gives everyone a chance to assess the situation and determine if it’s a good cultural fit. Also, some hospitals use temporary nurses to relieve their regular staff so they can attend training sessions for new technology or other major initiatives. Most recently, some hospitals have begun using travelers with the proper experience and credentials as interim nurse-managers and recruiters.

How would I go about choosing a travel nursing company?

Shaffer: If the adventure factor is important to you, look closely at the number of jobs available and their locations when choosing a staffing firm. Usually, the larger the firm, the greater the selection of jobs and locations offered.

Is travel nursing the same thing as agency nursing?

Shaffer: No. Some people mistakenly lump all supplemental nurses—travelers and agency nurses—in the same category. But there’s a difference: Agency nurses are per diem nurses who practice locally and don’t travel. Typically, they fill in for a day or several days. They don’t necessarily have the same education or experience as traveling nurses. Travelers, on the other hand, are fixed-term, temporary nurses who usually work at the same hospital for 13 weeks and are scheduled at least 2 months in advance. Hospitals are likely to depend on travelers for more specific or strategic staffing needs, such as to provide continuity of care when covering for maternity leaves, vacations, or sick leaves.

As a travel nurse, how often would my job performance be evaluated?

Shaffer: Travel nurses are evaluated more often than the average permanent staff nurse. They receive yearly performance evaluations from their employers and more frequent evaluations from hospital-based nurse-managers for each assignment—typically at least four evaluations each year. Also, before each new assignment, nurse managers and human resources personnel at the next hospital where travel nurses plan to work interview them and evaluate their work experience and records.

Does the staffing firm offer the traveling nurse any support while on assignment?

Shaffer: Staffing firms employ many people who work on behalf of their travelers. For the traveler, the most important support person is the recruiter. The recruiter is always there for the traveler, acting as a career lifeline and helping the traveler get the positions he or she wants. These firms also employ registered nurses to serve as clinical liaisons and career coaches and help travelers to solve problems and deal with emergencies. Other dedicated support personnel at staffing firms include chief nursing officers, educators, and specialists in risk management, workers compensation, payroll, and credentialing.

What qualities should I look for—or look out for—in a travel nursing company?

Shaffer: Most travel nursing companies work hard to assure quality for their clients and good working conditions for their travelers. As in any industry, the quality of the goods and services provided varies from poor to outstanding. The Joint Commission (TJC) has a certification program that helps hospitals determine whether a staffing firm can provide competent staffing services. A number of staffing firms have been certified—and recertified—and many others are seeking certification. For a list of certified staffing firms, visit TJC’s website at
www.jointcommission.org. And, of course, you can ask traveling nurses for their recommendations.

I’ve heard a few nurses say it’s mainly the poorly run hospitals with heavy workloads and high turnover that use travel nurses. Is this true?

Shaffer: Absolutely not. More than 80% of Magnet® hospitals in the United States contract with staffing firms, including many leading medical centers. Magnet facilities use traveling nurses strategically—for instance, to cover for vacations and leaves of absence, to maintain morale by providing appropriate nurse-patient ratios, and to ensure constant delivery of high-quality and safe patient care. The vast majority of TJC-accredited hospitals contract with more than one staffing firm to help them meet fluctuations in demand.

Is the travel nursing industry likely to be around for a while?

Shaffer: Thanks to mandated staffing ratios and the desire of many nurses for freedom and flexibility, staffing firms most likely are here to stay.

Franklin Shaffer, EdD, RN, FAAN, is chief executive officer for CGFNS International in Philadelphia.

Dealing with difficult people

Jackie Jacobs is a charge nurse in a busy intensive care unit. She prides herself on being able to get along well with almost everyone on her team. But when she sees Amanda’s name on the evening’s work schedule, she braces herself for the inevitable confrontation that will arise when she gives Amanda her patient care assignment.

Amanda has a reputation for being a difficult person. She’s also an experienced and competent critical care nurse capable of caring for complex patients. Tonight, Jackie has many new graduates working in the unit. She will need to assign Amanda two challenging patients. She anticipates Amanda will immediately criticize her judgment and complain about her to anyone who will listen throughout her shift.

Charge nurses like Jackie have a unique challenge because they lead teams and manage patients, even though they have little formal power. When all is working well on the unit and with the team, this isn’t a problem. But when a staff member, patient, physician, or family member is difficult to keep happy, your role as a charge nurse may become much more challenging. Learning to work with difficult people is both an art and a science.

How difficult people differ from the rest of us

We can all be difficult at times, but some people are difficult more often. They demonstrate such behaviors as arguing a point over and over, choosing their own self-interest over what’s best for the team, talking rather than listening, and showing disrespect. These behaviors can become habits. In most cases, difficult people have received feedback about their behavior at some time, but they haven’t made a consistent change.

Part of what motivates difficult people is that they can wear people down and get what they want. A nurse like Amanda probably has learned that by complaining, she can avoid challenging assignments even if these are in the best interests of patient care. (See Is she a bully or a difficult person?)

Difficult personality types

Leadership consultant Louellen Essex identifies four types of difficult personalities. You can probably identify the personality types of some of the difficult people you deal with from the list below.

  • The Volcano is abrupt, intimidating, domineering, arrogant, and prone to making personal attacks. Using an extremely aggressive approach to get what he or she wants, the Volcano may behave like an adult having a temper tantrum. Volcanos don’t mind making a scene in a public place.
  • The Sniper is highly skilled in passive-aggressive behavior. He or she takes potshots and engages in nonplayful teasing. Snipers are mean spirited and work to sabotage their leaders and colleagues.
  • The Chronic Complainer (like Amanda) is whiny, finds fault in every situation, and accuses and blames others for problems. Self-righteous, Chronic Complainers sees it as their responsibility to complain to set things right—but rarely bring solutions to the problems they complain about.
  • The Clam is disengaged and unresponsive, closing down when you try to have a conversation. He or she avoids answering direct questions and doesn’t participate as a team member.

Changing your response

You may not be able to change a difficult person’s behavior, but you can change how you respond to it. By learning to disengage effectively, you can avoid getting hooked into the difficult-behavior cycle.

When responding to a difficult person, you have several choices—doing nothing, walking away, changing your attitude, or changing your behavior. Doing nothing may not be the best choice because over time it can lead you to become increasingly frustrated (as Jackie has become with Amanda). Walking away may not be an option if you need to work closely with the person. Changing your attitude and learning to view the behavior differently can be liberating.

Ultimately, though, changing your behavior is the most effective approach because the difficult person then has to learn different ways of dealing with you.

Tips for coping with difficult people

Below are some great tips from life coach and speaker Stephanie Staples.

  • Don’t try to change the difficult person. Generally, difficult people have well-established behavior patterns. Any behavioral change will come only if they take accountability for it. You can point out the undersirable behavior, but it’s not your responsibility to change it.
  • Don’t take it personally. Their behaviors reflect where they are personally, not anything you might have said or done. They may be ill or tired, or they may have extreme emotional problems. When you see an explosive reaction to a minor situation, you can be sure the person is experiencing strong underlying emotions.
  • Set boundaries. Let the difficult person know you’ll respect him or her, but expect to be treated with respect in return. Don’t tolerate yelling or heated conversations in public places. If necessary, tell the person you need to remove yourself from the situation, or wait until the person is able to have a discussion without an angry reaction.
  • Acknowledge the person’s feelings. You may not agree with the person’s viewpoint, but you can acknowledge that he or she appears angry or unhappy. With a chronic complainer, you’ll need to move from the complaint to problem solving.
  • Try empathy. Recognize that it must be difficult to be stuck in a place of negativity or anger. Empathy can sometimes help deescalate an explosive situation. Difficult people sometimes just want to be heard but don’t have the skills to communicate that in a more appropriate way.
  • Hold your ground. Teach others how to treat you. Don’t open the door to challenges. With snipers, you may need to expose their behavior publicly to other team members.
  • Use fewer words. With difficult people, less conversation may be more effective. Use short, concise messages to drive your point home, and set a time limit on how long you’ll engage in the discussion. Avoid using the word “attitude” because the person will view this as subjective. Instead, focus on the behavior.

Although these tips aren’t guaranteed to work every time, you’ll find them helpful in many situations. Remember—in the end, the only behavior you can truly control is your own.

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Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.
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Rose O. Sherman is an associate professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton. You can read her blog at www.emergingrnleader.com.

Stranger in a strange land

What’s it like for faculty to teach in another country? This article gives the reader a glimpse into the experience through the international travel of four faculty members.

Each faculty member chose a single transformative event of informed personal knowing that shaped their views of transformative international learning. These professionals use storytelling as a method of describing Mezirow’s “disorienting dilemma” (an inner experience of disequilibrium). Such a dilemma can be sudden or build over time. Discover how these faculty members, faced with external and internal crises, dealt with their situations. First, it is important to understand the concepts of transformative learning and disorienting dilemmas.

About transformative learning and disorienting dilemmas

Transformative learning was introduced by Jack Mezirow in 1978 when he described the experience of women returning to college. In 1991, Mezirow wrote, “Transformative learning, using critical reflection, results in the reformulation of understanding one’s experience.” By developing methods of reflecting on the disequilibrium that results from disorienting dilemmas, initiated by internal or external personal crises, perspective transformation can occur.

Disorienting dilemmas (DDs) are also opportunities to expand personal ways of knowing. Carper described personal knowing as the development of knowledge through experience and participation. International travel, especially during a first visit to another country, often leads to varying levels of internal or personal crises. Internal DDs can occur as a result of changes in weather, jet lag, or intestinal distress from a change in food (internal crisis). External personal crises can occur as a result of reactions to class distinctions, unfamiliar social norms, or even differences in nursing practices. In our experience, DDs have been an important part of promoting deep learning through immersion in another culture.

The following stories describe significant events that resulted from international travel as visiting professors. Each author self-selected the following exemplars after reflecting on significant learning experiences during travel.

From China to the United States

Background. In China, it’s very common for female faculty to work only until the age of 55. After completing my master’s degree, I returned to my hometown and joined the faculty at my medical college. In my area of China, being a mother, wife, and respected faculty member at 35 years of age is the time to work and enjoy life. I am not expected to continue my education to doctoral studies as a woman since I am over 30 years old and have a young child and a husband who works in another city and is seldom at home.

Disorienting dilemma. My view about aging totally changed when I came to the United States as a visiting scholar in the fall of 2012. I quickly learned that obtaining a doctorate after the age of 35 years was common. One of my mentors pursued her Ph.D. when she was 45 years old and is now 57. She is well past the time of retirement from a Chinese perspective. At 57 years old she works very hard, spends a lot of time helping others in research and developing international partnerships. Another mentor is 73 years old and still works full time as the director of a nursing program. I was shocked by the age of faculty and their levels of energy.

Perspective transformation. My perspective about my career has been totally changed. The possibility of completing a Ph.D. may open up an opportunity to me even at 40 years of age. I plan to enter a doctoral program when my daughter is older.

From Europe to the United States

Background. After several successful years of faculty exchanges between our public university and a small European university, two students from a European country came to spend several weeks on campus as part of a global community health class. It was a first for the department and excitement was high. During the initial days of the visit, the students asked to attend a national rally of a well-known political leader. The students were taken to the event as a way to introduce them to the American political system. Upon arriving at the convention, an older gentleman overheard the students talking about their excitement and generously offered three tickets to the front row area of the event.

The excitement in the convention center was most accurately described as that of a Beatles concert. As the speakers finished their presentations, the keynote speaker came on stage to the shouts and adulation of a screaming crowd of several thousand people, many of whom were seniors.

Disorienting dilemma. From the beginning, the speaker launched into an attack on the health care system of the same country the students were from. Within seconds, the students’ excitement turned to shock and despair. My self-image as a protector and facilitator of learning was transformed to feelings of inadequacy and failure. There was no way to leave the event, because of the location of our seats in the front. It took several days of debriefing the students to re-establish a general sense of goodwill and psychological safety for the students.

Perspective transformation. In the span of a few moments my view of myself as a facilitator of learning turned to one of being derelict in my duty as a protector of the students. I felt that I had let them and both universities down by failing to consider all the possible consequences of taking the students to an event I had not experienced before.

From the United States to Africa

Background. In order to understand my disorienting dilemma it is important to give the reader a glimpse into my psyche as an American who is Black and of African descent. I have been at odds with the variety of labels affixed to Americans who are Black, including Negro, Colored, Afro-American (a hairstyle), Black, and most recently African-American. For the last 30 years the racial group I identified with was “Black.” Based on societal expectations and their comfort level, I settled into being labeled “African-American.” This assumption was shattered when I traveled to Africa and I was identified as Black.

Disorienting dilemma. Upon arriving on the African continent, I felt at home. I saw many beautiful women with short hair and shaved hair. Some were bald. However, the Africans I met seemed to resent my inference of being “African-American.” This caused some distress, since in my homeland I was not embraced/accepted as an vAfrican-American.” This shattered my sociocultural assumptions of “who am I.” I felt confused because with my peer group I was an “African-American” and with my ancestry group I was a “Black American.”

Perspective transformation. Luckily, I was not alone in this dilemma, as the other members of the group experienced the same encounters and reactions. My transformative learning experience changed how I viewed my place in the world. I had always believed I was an American who happened to be Black and this encounter validated my assumptions as accurate. I am not a hyphenated American.

The trip finished with a visit to the historic slave castle on the Ivory Coast. This was the door of no return for a slave. The smell of women’s blood was still evident in the women’s quarters. At the beginning of this journey I saw the world as Black and White. Anyone who had color was put into the black box and others into the white box. My worldview has transformed to include the various shades of color with all the inherent diversity. I now approach diversity from the perspective of inclusion rather than exclusion.

From the United State to Afghanistan

Background. The intention of my global role as a nurse expert is to be an ambassador for my discipline and the United States. In 2006, I was honored to join a group of American and Canadian nurses who volunteered to visit Wazir Akbar Khan in Afghanistan for a month. Although my family thought traveling to Afghanistan may not have been safe, I felt called to provide this service as a professional nurse and Moslem Muslim who believed in the values of international service.

Disorienting dilemma. Living at the margins of society in a war-torn country like Afghanistan provides a daily reminder of the fact that you do not know if you are going to survive the day. This awareness was mentally and physically exhausting. One day while speaking with a local clinician I learned that the staff questioned our motives for volunteering.

Some nurses thought our mission was to convert them from Islam to Christianity. I was shocked that the local clinicians questioned our motives, given the extreme personal sacrifice this trip entailed. I wanted to clarify our motivation to put our colleagues at ease.

I asked the translator to explain how his team arrived at this conclusion. The answer was “despair” from years of turmoil beginning with the Russian occupation decades ago to the current US intervention; many people, including nurses, have lost hope. They could not conceive of Western nurses traveling across the globe with a singular goal of helping other nurses while expecting nothing in return.

Perspective transformation. After some heartfelt conversations with nursing leaders we clarified our intentions and continued to provide a full schedule of daily patient care, staff development, and curriculum planning. We ate in the cafeteria with the staff. We also enjoyed the beautiful landscape of Kabul in spite of the hundreds of bullets holes in the walls of homes, hospitals, and even Kabul University.

During the trip there were many days we thought we would never survive. In spite of the turmoil, I would return to Afghanistan if given the opportunity. Travel brings people closer together and helps us understand each other.

Power of story

Storytelling is an important technique for sharing experiences and passing on shared knowledge. International travel transforms everyone who ventures out of the comfort zone. The experiences are priceless to us. Being immersed in another culture with nursing colleagues highlights more similarities than differences in practice. Thus, we recommend all faculty members take the first step to immerse themselves in another culture.

Qilian He is an assistant professor at Medical College of Qing Hai University. Marilyn Smith-Stone, Ora Robinson, and Asma Taha are all assistant professors in the Department of Nursing at California State University San Bernardino.

Selected references

Gaydos HL. Understanding personal narratives: an approach to practice. J Adv Nurs. 2005;49(3):254-9.

Grassley JS, Nelms TP. Tales of resistance and other emancipatory functions of storytelling. J Adv Nur. 2009;65(11):2447-53.

Mezirow J, Transformative dimensions of adult learning. California: Jossey-Bass; 1991:91.

Dirkx J, Mezirow J. Musings and reflections on the meaning, context, and process of transformative learning: a dialogue between John M. Dirkx and Jack Mezirow. Journal of Transformative Education. 2006;4(2):123-39.

Christoffersen JE. Leading a study-abroad group of nursing students in Nicaragua: a first-timer’s account. Nurs Forum. 2008;43(4):238-46.

Garner BL, Metcalfe SE, Hallyburton A. International collaboration: a concept model to engage nursing leaders and promote global nursing education partnerships. Nurs Educ Pract. 2009;9(2):102-8.

McMillan LR. Exploring the world outside to increase cultural competence of the educator within. J Cul Divers. 2012;19(1):23-5.

Smith-Stoner M, Let international travel transform you. American Nurse Today. 2008; 3(3). Available at: https://americannursetoday.com/article.aspx?id=4910&fid=4860. Accessed June 2, 2013.

From our readers: Pack your bags: Preparing for a global health nursing experience

More American nurses are venturing out into the world to offer their skills, even if only for a short period of time. Maybe it’s earthquake or cholera relief in Haiti, rural community health in Latin America, military duty overseas, or a short-term mission trip to Africa. No matter where you go, you need to prepare so you can make the most of your experience.

Inside the bubble

We all exist in an invisible “bubble”—an insulating set of comforts and expectations to make daily life easier and predictable. The “bubble” consists of familiar routines. It’s also a set of cultural assumptions, most of which are taken for granted. For example, whether which side of the road you drive on, the way a toilet operates, table manners, or the proper greeting when you meet a stranger.

To use your nursing skills in a foreign location is a challenge unlike any other. A trip to a low-income country off the beaten path qualifies as “adventure travel” with unpredictable elements. When you combine travel and nursing practice, you are going behind the scenes, to the places the usual tourist does not go, and meeting people on their own turf, in settings not in the guidebooks. You’ll need to learn a whole new set of travel skills. Here is a short list of things to consider.

Choose an NGO. NGO stands for “Non-Governmental Organization.” The most well known are Doctors Without Borders and the Red Cross, but there are literally thousands of groups working all over the world. An NGO will pave the way for you to use your skills fully. Often, you’ll be plugged into an existing program that will fit your needs. Some NGOs also help you with in-country travel and such things as food shopping.

Learn the language. Take language lessons. This is the single most important long-range skill required for most global health experiences. Nursing depends on making a person-to-person connection and dealing with the patients face-to-face. In a clinical setting you can’t always count on having an interpreter. Being able to say hello, navigate the local bus system, and order at a restaurant will ease your transition.

Meet somebody who is from there. In the largest American cities nowadays, you can find small pockets of people from nearly every society on earth—this is an amazing resource. Use the Internet or go to your local college to find somebody who is from the country you will be visiting. They can become a source of valuable information in all sorts of ways. Before I left for my first trip to Nepal I found a Nepali language tutor by posting a small flyer on the wall of the only South Asian grocery store in Honolulu. She taught me about language and customs such as table manners and greetings. Befriending a person from a different culture is a two-way street and has many advantages. It is something we can all do even if we have no intention of leaving home.

Go camping. Learn how to get by with fewer creature comforts than the typical American. If you have never prepared food using primitive equipment over a wood fire or used a privy, these skills will open your eyes to the daily challenges faced by rural people all over the world. Start to walk or hike regularly—if the transportation system is poor, you may find yourself walking a lot more than usual. Know that in some cultures, coffee is not a daily menu item. If you must have coffee every day, learn how to make it using a wire mesh filter.

Eat the food. This starts with going to an ethnic restaurant if there is one available. Be aware that in countries where cooking is the role of women, you can better understand this role by familiarizing yourself with food preparation and the time it takes.

Read the literature of the country. Start with a Lonely Planet tourist guidebook; these usually include the elementary rules of etiquette. You can learn about religion, politics, gender roles, customs such as those surrounding funerals, and body language.

Plan for culture shock and re-entry shock. Culture shock arises from the inevitable comparison to your home. Re-entry shock is something that sneaks up on you—it happens when you return, expecting to take up your life where it left off, but realize that you have changed in unexpected ways. It is not unusual after a global health experience to feel disconnected from your home culture.

Minimize your baggage. I have a friend who has led 10 trips to rural Nicaragua. She blushingly confessed to me that she brought a hair dryer with her the first time. On each subsequent trip she learned what she did not need. Nowadays, she travels very lightly, with only as much as she can fit in a daypack, for a 3-week trip.

Plan to share from the beginning. We owe it to our fellow Americans to educate them about global health, and a firsthand account is powerful. Get a camera and practice with it before you go. No matter how much you tell people, they will never understand what it was like unless you have photos when you return. If you buy souvenirs or artifacts, choose ones that tell a story about the daily life of the people. Keep a journal.

Learn about hospital and clinic standards. Many of the health problems in low-income countries are directly traceable to lack of public health infrastructure. There will likely be more problems with infectious diseases. You may end up learning how the local providers deliver care even though disposable supplies may be limited or they may not have new equipment.

Practice “water discipline” and food sanitation. Clean water is something we take for granted. Food- and water-borne illnesses are the single biggest problem encountered in foreign adventure travel. In many countries the water from the tap is unreliable. It is helpful to practice safe ways to use water that will become firmly engrained habits before your trip. Visit a travel clinic and start getting immunizations in advance.

Pop the bubble. Even if the primary purpose of foreign travel is vacation, and you aren’t planning to use your nursing skills, there are some things you can do to gain wider experience with other cultures. For example, if you go to the Caribbean, you can get out of the bubble by spending a half-day touring a local hospital. Often, somebody will gladly show you around even if you give limited notice. In low-income countries, up-to-date nursing textbooks are beyond the reach of local healthcare workers. Pack one with your luggage as a gift for the hospital library, and you will contribute to local health care even if it is a small way.

A global attitude

An experience in global nursing can be very rewarding if you prepare properly. Even if you never leave home, you can benefit from adopting a global attitude.

Joe Niemczura, who is a faculty member at the University of Hawaii, is planning his fifth summer-long trip to teach nursing in rural Nepal. His is the author of the book, The Hospital at the End of the World. Nurses are invited to visit Joe’s blog to see photographs and videos depicting hospital care in a low-income country.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

volunteer nurse abroad

From our readers…How to volunteer as a nurse abroad

Azure Window, Gozo, Maltese Islands. When I took the ferry to Gozo, Malta’s sister island, the Azure Window was a nice place to visit. When I was in nursing school a U.S. Peace Corps Volunteer talked to us about his experiences in the Pacific Islands. I was on fire to join and did so years later. Before I signed up, however, I alternated between working in critical care units and traveling. I eventually realized that when employed as a nurse I poured over travel brochures and when traveling, the hospitals of other countries intrigued me. Continue reading »

Today’s Traveler: Pack your bag!

As a traveling nurse in the operating room since 1997, I have gained more knowledge and experienced a variety of cases I would not have experienced if I had stayed in a permanent position. It takes strength in experience and ability to be flexible to be a successful traveler. Hospitals want the traveler to have a maximum of one to two weeks of orientation, and then be able to perform independently. Time is money, and for travelers to be successful they have to have to learn and adapt quickly.

The traveler’s contract is usually for 13 weeks, but can vary. If the hospital needs travelers to stay and they are willing, the contract can be extended. Having several travel company’s paperwork completed is essential to having a variety of job options.

Doing research on the area and hospital you want to go is essential. Traveling is very rewarding and the experience one gains is amazing! So go pack a bag and hit the road!

Submitted by Catherine Kranske, RN,BSN, Chattanooga, Tenn.

Getting serious about going global

Many nurses are seeking ways to serve disadvantaged or imperiled populations around the world. Not long ago, we assumed someone else would step up to meet the needs of such populations. Today, most of us realize that “someone else” might well be us.

In both global and domestic crises, roles for nurses are increasingly diverse. From the earliest warning stage of a crisis through long-term recovery, the needs of vulnerable populations call for creative and culturally appropriate interventions along with clear-headed thinking and an organized approach to care delivery. Such interventions cost time and money and present political and logistic problems and, in some cases, danger. However, settings that pose extreme personal and professional challenges can be indescribably rewarding.

Planning your global experience
Planning when, where, and how to work in a global setting is essential. First, reflect on your reasons for seeking the experience. Then research the many available options. Thousands of secular and faith-based organizations and government programs respond to global crises. You can find most of them by searching “humanitarian resources” on an Internet search engine. Study the organizations’ mission statements. Find out what types of programs each organization administers and their site locations; trace their programmatic and financial histories. If you have questions that the website doesn’t answer, contact the organization directly.

Exceptions exist, but know that major world nongovernmental organizations (NGOs) don’t give you a choice about where you’ll go, or when. While the major NGOs usually require a commitment of at least 6 months, they cover all expenses. Other types of organizations, particularly church-based initiatives, will let you work on an international project for as little as 1 week but require that you pay all expenses.

Applying to an organization
After narrowing the field, apply to the organizations with positions that best match your skills and available time frame. Always provide honest information in your application. If you have medical problems or limitations, be honest about this upfront—not when you are in the field and may have to be treated and possibly airlifted out (which can cost more than the whole project’s budget).

Expect to wait at least several weeks to hear if you’ve been accepted, and even longer to receive a mission assignment. The larger medical relief agencies that recruit worldwide prefer to place people with international experience; being fluent in another language also can help. Exceptions exist during acute emergencies; for instance, surgical or ICU nurses may be accepted when an emergency operating theatre must be set up in the field. (See “Don’t just drop in” in pdf format by clicking the download now button.)

An important caveat: Even if you have the right skills and apply at the right time, you should accept a position only if you really want it and are qualified for it. If you wouldn’t take a similar job at home, don’t accept it from a humanitarian aid organization.

Tips for getting accepted
You may have a better chance of being recruited by an international relief organization if you:
•    have experience in international settings
•    have worked previously in disasters or emergencies
•    have a history of working independently, especially in rural or remote areas
•    can speak another language
•    have demonstrated skills in a particular area, such as emergency medicine, women’s health or midwifery, or public health or epidemiology
•    are in good health.

”I’ve been accepted! Now what?”
Once you have accepted an assignment and been given a departure date, you and your loved ones may have conflicting emotions about your leaving. Explain to them that while you’re away, you may not be able to have the close contact you or they might like. Although cell phones are everywhere these days, the power to charge them isn’t. E-mail can be unreliable, and you’re likely to be one of many people trying to stay connected. To dispel your family’s worries, tell them to assume no news from you is good news; if something goes wrong, your organization will call them.

What to expect when you get there
Organizations differ with their protocols, but ideally you will receive orientations at the organization’s stateside office or by phone before departure, when you arrive at the group’s headquarters in-country, and at the project site. Each orientation may differ somewhat. The information you receive at the group’s U.S. office is bound to be less up-to-date than what you’ll learn from the on-site coordinator at the destination. However, all orientations should have a reasonably consistent theme about your role and responsibilities.

Before leaving for your destination, ask who will meet you at the airport. Culture shock can be severe—especially during your first time at the airport of a developing country. You may feel overwhelmed by the crowds and taxi drivers hawking their services. Typically, a driver or a representative of the organization will be waiting for you with a sign bearing the organization name, or you’ll receive instructions on which taxi or car to take. Keep in mind that you can’t just go to a telephone and make a call without first getting local coins and knowing the language. Important: Make sure you know the name your organization goes by among the locals, as well as the address and local phone number of the place where you wish to go.
When you get to the site, you’ll probably feel extremely tired and confused. You may even question whether you were sane when you made the decision to go global! But with a little time, sleep, and a welcome from your team members, things will soon feel right.

In the field
Some nurses can become embedded in a project quickly, especially those with a specific job description and delineated responsibilities. Be aware that responsibilities may shift and flexibility is critical. For example, if you’re responsible for administering measles vaccine in a refugee camp, you may become expert in your job quickly. However, if a cholera outbreak occurs in the camp, you may be needed to help identify and test contaminated wells. While that task may fall outside your expectation, comfort zone, or expertise, it’s just as important as your usual responsibilities. “That’s not my job” is rarely heard in an effective, cohesive relief team.

Appreciate the national staff
The organization’s national staff is your best source of information on how to serve the population, as well as on daily life in the community. They can be your lifeline—especially those who serve as drivers and interpreters. Never underestimate their value to you, to the project overall, or to the future of the local population. Long after you’re gone, the national staff will remain.

Security concerns
How safe is humanitarian work? While the incidence of harm to humanitarian aid workers has been rising, rarely are these workers intentionally targeted for harm. In fact, traffic accidents remain the single greatest risk.

In cases of acute crisis, the United Nations is often in charge of overall security, but all organizations have their own rules, regulations, and codes of conduct. As a team member, you are expected to abide by them and usually sign in writing that you will do so. Ultimately, each person is responsible for making good judgments and decisions. To do otherwise may bring consequences or repercussions with far-reaching implications for the individual, the team, and the whole project.

Team tensions
On a global relief mission with team members of varied backgrounds, nationalities, and temperaments, tensions develop from time to time. Team dynamics are a common cause of stress, especially when team members share a house and work in difficult circumstances. Paradoxically, the tougher the mission and the more extreme the hardship, the fewer complaints arise—perhaps because team members have little time to worry about trivial things and a greater need to rely on one another.

Saying good-bye
Most international aid workers find leaving their missions a wrenching experience; the longer they’ve been there, the harder it is to leave. Love of the land, the people, and the way of life tends to become part of your life, and you know you’ll never be quite the same. (See Stop short of making promises in pdf format by clicking the download now button.)

Upon departure, your organization may debrief you. Debriefing is an opportunity for you to report the facts as you’ve observed them. It can be extremely cathartic. If you’ve experienced or witnessed atrocities, violence, or danger, the organization should provide a professional mental health debriefing protocol as well as follow-up contact.

Back at home
When you return home, expect to feel disoriented. You may have trouble describing your experience to family and friends. Even if they want to hear all about it, there’s a limit to what they actually want to know. After all, they have no visual images and only a limited context in which to wrap your stories. What they most want is for you to get back to being you and living your life as before. That may take time, however, and you may feel lonely with your thoughts and memories for a while.

During your transition to “normal” life, staying connected to people from the organization or finding others in your community who’ve had similar experiences can help. They’ll understand how hard it is to walk into a massively stocked supermarket still haunted by the faces of the hungry, malnourished people you left behind. Be assured, though, that just as you were able to adjust to a new place weeks or months before, you’ll readjust to life at home.
Going global has its risks and hardships, but they are usually outnumbered by rewards, wonders, and a profound sense of purpose. You have much to offer. Take the responsibilities of a global mission seriously and savor it as one of the most important ventures of your life—as a nurse and as a citizen of the world.

Carol Etherington is an Assistant Professor of Nursing and Director of Global Health Studies with the Institute for Global Health at Vanderbilt University in Nashville, Tennessee. She has worked in 13 countries, primarily in acute disaster and conflict settings with the international humanitarian medical relief agency Médecins Sans Frontières/Doctors Without Borders.

operation_smile children kids volunteer

Far from home, bringing smiles to children’s faces

During my three decades as a nurse, volunteering on a medical mission has always been on my “to do” list. In 2005, having finished my nursing education and with an empty nest at home, I finally had the time and wherewithal to commit to such a mission. After exploring various options, I decided to apply to become an Operation Smile volunteer. Continue reading »

Nursing in Afghanistan: A cultural perspective

In any practice setting, nurses must strive to provide culturally competent care. For healthcare professionals working beyond America’s borders, incorporating cultural sensitivity into patient care is especially crucial.In Afghanistan, both military and civilian nurses face the challenge of providing culturally appropriate care in a country with a poor economy and minimal healthcare assets. As the Afghani government matures and the country stabilizes, greater efforts will be made to rebuild the healthcare infrastructure.

Like other healthcare providers deployed with the 14th Combat Support Hospital (CSH) to Afghan­istan in support of Operation Enduring Freedom VII, I discovered firsthand the importance of integrating a patient’s cultural preferences into the plan of care. From February 2006 to February 2007, medical personnel at the 14th CSH cared for a diverse population that included American soldiers, Afghani civilians, Afghan National Army soldiers, and other Coalition soldiers from around the world. Afghanis accounted for about 85% of the inpatient population and required the greatest level of cultural sensitivity. Many had severe, debilitating injuries that necessitated extensive medical care. During their lengthy hospital stays, the staff’s cultural savvy was critical to their recovery.
A vulnerable population
Most Afghanis who seek health care at American or Coalition hospitals in Afghanistan are extremely sick, severely injured, or near death. Many end up at these hospitals after being turned away from (or treated unsuccessfully at) Af­ghani hospitals—in most cases, due to lack of equipment or expertise to treat their conditions. Those who seek medical care at American facilities (whether in Afghanistan or the United States) are vulnerable to misdiagnosis, mistreatment, and misunderstanding because they’re unfamiliar with Western medical practices.Afghanistan’s healthcare infrastructure is one of the poorest in the world. In many rural areas, nearly two decades of war have rendered health care virtually nonexistent.

The environmental health situation is deplorable, too. Only about 7% of Afghanis in urban areas have safe sanitary disposal facilities. Access to high-quality health care is limited, and one in six children dies by age 1.
Barriers to improving Af­ghan­istan’s healthcare infrastructure include:
• lack of educated physicians and nurses to staff the few medical facilities that exist
• poor roads and transportation, which pose obstacles for Afghanis in rural areas who seek care
• an extremely weak economy and lack of money to initiate new healthcare programs
• too few universities to educate healthcare professionals.
Understanding Afghani culture
Whether Afghanis seek care in their native land or in the United States, cultural considerations for healthcare workers center on religion (Islam) and family. Afghanistan’s culture is deeply rooted in Islam. Even in times of sickness, prayer is an extremely important part of daily life. Inability to pray can cause much anxiety and stress.
To decrease stress and make Afghani patients and families feel comfortable and welcome, direct them to clean, appropriate prayer areas and tell them which direction faces Mecca. Afghanis place great importance on the Koran and other religious materials, so try to make these items available or find out how to access them.
Also recognize that Ramadan is the most significant time of year for those of the Islamic (Muslim) faith. Lasting 1 month, Ramadan starts on the first new moon of autumn. It’s a time for inner reflection, devotion to God, and self-control. During Ramadan, Muslims fast and avoid med­ications and sexual activity from sunrise to sunset. Although these restrictions usually don’t apply to extremely ill or hospitalized patients, they must be addressed with patients and their families.
Know that eating in front of someone who’s fasting is consid­ered disrespectful. During Rama­dan, make sure morning and midday meals aren’t delivered to Af­ghani patients’ rooms, and urge other staff members to avoid eating in front of patients and their families.
Family focus
When an Afghani patient seeks health care, the father, the eldest son, or an elderly uncle serves as family spokesperson. Traditionally, Afghani women are considered the primary caregivers outside the hospital environment—but this wasn’t always the case when patients were admitted to the 14th CSH. In Af­ghan­istan, males act
as primary caregivers for family mem­bers admitted to American hospitals. (In the United States, Af­ghani women may take on this role.)To properly recognize the family’s role in Afghan culture, allow one family member to stay with the patient to act as caregiver. If a female Afghani is admitted to the hospital, be aware that a male chaperone may need to stay with her as an escort throughout her hospitalization.

Other cultural considerations
Certain Afghani cultural beliefs may inhibit self-care and healing—and healthcare providers must consider these when formulating the patient’s plan of care. For instance, some patients may not want to ambulate, believing they need to preserve their energy for healing. In this case, encourage physical therapy exercises, but be sure to explain why they’re important to recovery.Also, try to arrange for the patient to go outdoors. Many Afghanis believe the sun has healing properties and enjoy sitting in the sun to absorb its energy.

Be aware that many Afghanis are relatively uneducated and may get confused when physicians and nurses explain medical information or treatment options. Many would rather defer medical decisions to the physician.
Avoiding bodily exposure
When caring for Afghani patients of either sex, keep their bodies cov­ered as much as possible. For Af­ghanis, bodily exposure is embarrassing and shameful. Although such exposure is necessary in an extreme emergency or trauma, be sensitive to the patient’s feelings about this and cover the patient to the extent possible.Also try to keep your own skin covered when caring for Afghanis so as not to offend them. Although this may be somewhat inconvenient for hospital personnel, it shows Af­ghani patients that the staff is dedicated to cultural sensitivity.

When I worked at the 14th CSH, Dr. Walayat Shah, an Afghani interpreter, recommended that only female nurses and physicians care for female patients. An Afghani wo­man, he explained, is uncomfortable being touched by a man other than her husband or father. In some circumstances, her husband might shun her if another man touches her.
Know that Afghanis consider children (especially boys) sacred, and many of the rules regarding invasion of privacy don’t apply to them. For example, Afghanis aren’t offended when a child’s clothing is removed during a healthcare procedure. Also, Afghani children are expected to respect and obey adults, regardless of their relation­ship to them. ­

After-death care
When an Afghani patient died in the 14th CSH, we went to great lengths to ensure culturally correct preparation of the body. First, we notified an interpreter and a chaplain, who recited an Islamic prayer and provided guidance for preparation of the body. We turned the patient’s head toward the direction of Mecca, tied the large toes together to prevent the legs from spreading, closed the mouth and eyes to prevent evil spirits from entering, and kept the body covered at all times. Family members then claimed the body and completed the remaining burial preparation. By taking the few extra moments to carry out these steps, caregivers can influence the family’s perception of the quality of care their loved one received.

Creating cultural committees and competency
Healthcare practitioners preparing to deploy to or work in countries outside the United States need to learn everything they can about local customs and cultures. One way to ensure they’re well informed and able to provide culturally correct care is to form cultural committees or focus groups that research the local culture and create appropriate policies. Another way is for those who’ve worked overseas to publish articles describing their experiences so other healthcare workers get the message.The concept of cultural competency applies to all aspects of nursing care, including inpatient and outpatient settings, research, home health, and even nursing management. As U.S. societies throughout the world become increasingly multicultural, all nurses should strive to gain cultural competence, regardless of their practice setting, role, or specialty.

Selected references
Giger J, Davidhizar R. Culturally competent care: emphasis on understanding the people of Afghanistan, Afghanistan Americans, and Islamic culture and religion. Int Nurs Rev. 2002;49:79-86.Leishman J. Perspectives of cultural competency in health care. Nurs Stand. 2004;19
(11):33-38.

Reece B. Afghanistan: from war to hope. Soldier Magazine. 2005;March:14-19. http://
findarticles.com/p/articles/mi_m0OXU/is_3_60/
ai_n15677625. Accessed December 20, 2007.
World Health Organization (2001). Country profiles: Afghanistan. www.emro.who.int/
mnh/whd/CountryProfile-AFG.htm. Accessed December 20, 2007.

Daniel J. Yourk, First Lieutenant in the U.S. Army, served as an Emergency Room Nurse at the 14th Combat Support Hospital in Bagram, Afghanistan. The views expressed in this article are the sole responsibility of the author and do not reflect the official views of the Army Medical Department, Department of the Army, or Department of Defense.