Practice Matters

Viewpoint: Two American nurses visit Cuba’s healthcare system

Political relations between Cuba and the United States are rapidly improving. This transformation provides unique opportunities for the exchange of ideas, including ideas related to how health care in general and nursing care in particular are delivered in each country.

The common perception of Cuba, the Cuban population, and the Cuban healthcare system can be one of low expectations for positive outcomes; however, Cuba has a strong history of successful primary and secondary prevention. (See Cuban health care at a glance.)

Cuban health care at a glance

Statistics from the World Health Organization (WHO) support the positive outcomes of Cuba’s healthcare system:

  • The average life expectancy for males and females is 77 years and 80 years, respectively, compared to 76 years and 81 years in the United States.
  • Infant mortality rate is 4.76 deaths per 1,000 live births compared to 5.90 per 1,000 live births in the United States, according to the Central Intelligence Agency Factbook.
  • For children under the age of six, the WHO notes that Cuba reports 6 deaths per 1,000 live births, while the United States reports 8 deaths per 1,000 live births.
  • WHO recently validated the elimination of mother-to-child transmission of HIV and syphilis in Cuba.

These statistics are even more impressive when one considers that per capita healthcare expenditures for 2011 to 2015 in Cuba are significantly lower than in the United States—$603 versus $9,146 respectively, according to the World Bank Group.

Longstanding travel restrictions have meant that US nurses have not been exposed to Cuba’s healthcare system, so little is known about how Cuban nurses are educated and how they practice. However, we need to build relationships with Cuban nurses because they are key stakeholders in the Cuban healthcare system and because the exchange of ideas can lead to mutual learning and possible new approaches for nursing education and disease prevention. Nurses in the United States and Cuba already share one part of nursing history: Clara Barton worked in Cuba in the late 1890s. She was a prominent figure in Cuban nursing during her time in that country and she encouraged the development of formal education for nurses.

A learning journey

The authors of this article, two nursing faculty members from the University of Alabama, traveled to Cuba in March 2015. Our primary goal was to begin relationship building between the University of Alabama nursing faculty and nursing faculty in Havana, Cuba. A secondary goal was to observe and assess how nursing education, nursing roles, and primary and secondary prevention occur in Cuba.

Visits included a school of nursing, a polyclinic, a residential maternity home, and the Escuela Latinoamericana de Medicina (ELAM), an international medical school. During our meetings over the course of the trip, we were able to build a vivid picture of how nurses (and physicians) are educated and what it means to be a nurse in Cuba. What we discovered on our 6-day trip was often different from our preconceived ideas. Here is an overview of some of what we learned.


The care environment

The physical environment of the clinics we visited in Cuba differed from those in the United States and from what one might expect in a more developed and economically stable country. For example, buildings are old and have been repurposed from their original use. Doors and windows were left open, and there did not seem to be a concern about privacy or confidentiality.

In the areas we visited, we didn’t see the type of technology available in the United States. For example, the laboratory in the polyclinic relied on older, noncomputerized methods of assessing blood chemistries and x-ray machines appeared several decades old. However, we were told that the type of technology found in the United States is available at hospitals.

Education

The faculty and administration of the school of nursing were welcoming and excited to begin a dialogue with US nursing professors. The professors we met with were interested in a possible faculty exchange program between the University of Alabama and the School of Nursing of the University of Medical Sciences of Havana. Nursing research is highly valued in Cuba, and we believe the Cuban faculty saw value in potentially working with US nursing faculty in both research efforts and nursing education.

The Cuban nurse educators asked many questions about how undergraduate and graduate nursing students are educated in the United States, and the process by which faculty are appointed. They were proud to share how education is provided in Cuba and had much to tell us about expectations of student outcomes.

Students begin clinical experiences at the start of the nursing program, while integrating didactic learning about hard sciences (biology, chemistry, pathophysiology), as well as the art and science of nursing. There is a strong emphasis on public health and the delivery of healthcare in the community setting. A large proportion of nursing students’ clinical experiences are directly embedded in the community setting, which is quite different from that of US nursing students, whose clinical experiences are mainly hospital and inpatient based.

Cuba offers the same three levels of education for nurses as in the United States. Nurses have the option of the 5-year baccalaureate entry-level degree, a master’s degree (with specialization in a specific area), or a PhD in nursing. Progression from one level to the next includes masters and doctoral level course work and occurs only after carefully documented demonstration of learning outcomes and appropriate skills.

Practice

The role of the nurse in team care is crucial in Cuba. Nurses generally establish long-term residence in one neighborhood and clinic. Physicians may stay and live in the neighborhood or they may rotate out after completing their family medicine residency. The nurse is considered the “glue that keeps this duo closer to the needs of the families and individual residents,” according to authors Keck & Reed. The overarching goals for both nurses and physicians and the methods of health promotion and disease prevention are consistent between the two professions.

At each site we saw how nurses work as equals in a team concept with the physicians. Many times during our discussions, the physician referred to the nurse to answer questions on topics related to polyclinic operation, current public health efforts, and medical care decisions. Nurses appeared confident in their roles as equal healthcare providers. They were able to articulate how they contribute to positive patient outcomes and overall public health. Observation of nurses working with patients in the polyclinic, including triage in the emergency department, demonstrated mutually respectful and professional interactions.

As noted, nurses and physicians often live in the community where they serve. Many live in the same building as the Consultorio or clinic office. Patients are assigned a primary care team (nurse and physician) and are required to attend appointments. If the patient misses an appointment the physician or nurse will make an unscheduled house call to determine why the patient did not attend the appointment. This approach creates a relationship in which the team knows the patient and family well.

In the morning, the nurse works in the office. In the afternoon, nurses and physicians (either alone or in teams) visit patients in the home through scheduled and unscheduled visits. Nurses provide care to many different types of patients, from new mothers to elderly grandparents. They administer medications, such as insulin and immunizations, and provide education on home environment, hygiene, and disease prevention.

Strengths and opportunities

This opportunity to explore a small segment of the Cuban healthcare system was an important channel in beginning to understand the methods and processes by which the Cuban government and Cuban healthcare providers have achieved such significant public health accomplishments while managing with few resources. This care model should be studied for adaptation in both developed and developing countries.

Our conclusion was that the actual experiences were not consistent with the preconceived ideas. The people we met were excited to move forward with establishing open communication and promoting the exchange of ideas and information. Visits to health education and healthcare facilities were instrumental in demonstrating how the emphasis on primary prevention during the education of nurses and physicians is key in providing holistic primary care targeted at health promotion behaviors and supportive social services.

Although the Cuban people we met agree that state-of-the-art technology is lacking and affects their ability to care for complex, acutely ill patients, they do not see this as a challenge. The idea of stellar primary care, which prevents complex acute illness, along with relationship building and truly knowing patients is the key to this belief. The absence of technology compels healthcare providers to actually “touch” patients. They are very proud of the high level of skill required to diagnose illness without the use of technology. Our post-trip reflections helped us to better understand how this public health-based, low technology approach leads to clear expectations of healthcare providers’ roles, and to supportive interprofessional relationships.

We look forward to return visits to Cuba and also to hosting Cuban nursing faculty and nurses at our institution. We recommend, without hesitation, the continuation of efforts to bring both US and Cuban healthcare providers together for the exchange of ideas and evidence that supports improved patient outcomes and better public health strategies. Nursing is the perfect discipline to reestablish relationships and build bridges to fill healthcare gaps in both countries.

Selected references

Ardalan C. Clara Barton’s 1898 battles in Cuba: a reexamination of her nursing contributions. Florida Atlantic Comparative Studies Journal, 2011;12:1-20.

Erwin PC, Bialek R. A matter of perspective: seeing Cuban and United States health systems through a cultural lens. Am J Public Health. 2015;105(8):1509-11.

Keck CW, Reed GA. The curious case of Cuba. Am J Public Health. 2012;102(8):e13-e22.

Pan American Health Organization. Health situation in the Americas. Basic indicators. 2011. http://ais.paho.org/chi/brochures/2011/BI%5F2011%5FENG.pdf

World Bank Group. Health expenditure per capita (current US$). 2015. http://data.worldbank.org/indicator/SH.XPD.PCAP

World Health Organization. Cuba statistics. 2015. http://www.who.int/countries/cub/en/

World Health Organization. WHO validates elimination of mother-to-child transmission of HIV and syphilis in Cuba. 2015. http://www.who.int/mediacentre/news/releases/2015/mtct-hiv-cuba/en/

Debra Whisenant is an assistant professor, and Alice L. March is an associate professor and assistant dean for graduate programs at the University of Alabama Capstone College of Nursing in Tuscaloosa, Alabama.

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