Taking a Look at Cooperation

AN ASSESSMENT OF 24 YEARS OF A.I.D. TECHNICAL ASSISTANCE INNURSENG

AGENCY FOR INTERNATIONAL DEVELOPMENT DEPARTMENT OF STATE WASHINGTON, D.C. 20523 CONTENTS Page

Foreward .o rd ... v

I. THE SETTING ...... 1

I. BILATERAL HEALTH PROGRAMS AND TECHNICAL ASSISTANCE IN NURSING ..... 4 ...... 4 Bilateral Health Programs ...... 5 The Nature of Technical Assistance...... Technical Assistance in Nursing. 6 m. PROGRAM AREAS IN NURSING . 11 Public Health Nursing ...... 11 Nursing Education ...... 17 Schools of Nursing ...... 17 Schools of Auxiliary Nursing ... 19 Special Programs ...... 20 Nurse Teachers ...... 21 Hospital Nursing Services ...... 21

IV. THE USAID NURSE ADVISOR .... 22 Qualifications ...... 23 Orientation...... 23 Activities...... 24

V. FACTORS INFLUENCING NURSING DEVELOPMENT I . . 28 Role of Women ...... 29 Prevention Versus Cure ...... 30 Geography and Transportation ...... I. .. I . . 31 Language...... 31 Economics ...... 32 Government's Role ...... 32

VI. ACCOMPLISHMENTS ...... 34 Administration...... 34 Standards ...... 34 Nursing Education...... 34 Midwifery...... I.... 36 Public Health Nursing Services ...... 36 Hospital Nursing Services ...... 37 Development of Nurse Leaders ...... 37 Professional Nursing Associations ...... 38

VII. AN ASSESSMENT...... 39

Program Resumes ...... 42

in a Chilean nurse. Miss Catherine Kain, U.S. AIDYS first Chief Nursing Advisor congratulates iv FOREWARD

The purpose of this publication is to record the story of United States technical assistance in nursing as it has been provided by the Agency for International Development to developing countries in the past twenty-four years - technical assistance which is illustrated by a country vignette:

When the Islamic State of Pakistan was created by partition in 1947, it was estimated that there were some 350 nurses in the country to serve a population of over 70 million. To prepare future nurses, there were six schools of nursing with widely varying courses of study which graduated approximately 110 nurses each year. Nurse teachers for these schools were inadequate, both in numbers and preparation. There were no facilities for post-basic nursing education, no fully qualified public health nurses, and few trained midwives.

United States health assistance to Pakistan, which began in 1953, reinforced and supported the Pakistan Govern­ ment's own determination to improve the health and nur­ sing conditions within its country. Additional assistance was given by the World Health Organization and other international agencies. Today there are 23 schools of nursing in Pakistan. Admission requirements have been upgraded and standardized; all of the schools, to the best of their ability, adhere to the curriculum drawn up by the Pakistan Nursing Council, a body organized to reg­ ulate the practice of nursing in Pakistan. That such a body exists to provide control and direction of nursing education and practice is in itself a mark of significant progress.

A College of Nursing, offering courses for graduate nurses in administration and teaching, was established in Karachi in 1955. By 1965 it was graduating 30 nurses - annually with the advanced preparation necessary for administration and teaching in Pakistan's hospitals, health centers, and schools of nursing. It is anticipated that eventually this College will serve as a regional center for advanced education in nursing, meeting the needs of nurses from other countries in the region.

In addition to the nurses trainedat the College of Nursing, 52 others have received advanced preparation, mainly in public health nursing and nursing education, through AID participant training programs either in the United States or at the American University of Beirut. Formal courses for auxiliary workers, for lady health visitors (a type of public health nurse), and midwives are now given regu­ larly. By 1963 Pakistan had almost 3, 000 professional nurses and over 300 lady health visitors. These workers

v are serving not only in Pakistan's hospitals and nursing schools, but also in the 72 primary health centers that have been established in both the rural and urban areas of the country.

Pakistan's nursing needs continue to be urgent but, in the words of a Pakistani nurse, "great strides have been made in the few short years since the country was created. In remembering this, we look to the coming decades confident and reassured. The progressof the past l6years has, indeed, been phenomenal. "

The foregoing is a thumbnail sketch of one country assisted by a USAID program in nursing. Instead of Pakistan the illustration used might have been Brazil or Ethiopia or Thailand for, over the past 24 years, through the Agency for International Development and its pred­ ecessor agencies, the United States has provided technical assistance in nursing to 47 countries on five continents. The record, both of achievements and limitations, mustbe evaluated within the context of each country's culture, its individual needs and resources, its goals, and its potential for achieving them. This fact, in itself, suggests the urgency for periodic program review and evaluation, with accomplishments measured, not against United States standards, but against the settings of the various developing countries. It is trite to say that "the past is prologue to the future." Yet, it is hoped that the prime value of this report will lie not so much in its record of past achievements and present activities as in its direc­ tion for the future. Certainly, an analysis of the nature of AID as­ sisted nursing programs, of the needs, resources, and problems en­ countered in the various countries, of the differing approaches used and their effectiveness in bringing about change and improvement, should be helpful to planners of future programs of international technical assistance. As a basis for making this analysis, records and reports of the Agency for International Development and its predecessor agencies have been carefully studied. Interviews with nurses and other health service personnel who have been active in these assistance programs have added immeasurably to the study of the subject. Discussions with health personnel of various countries provided valuable insights into how they perceive their country's nursing needs, the progress made, and future goals to be attained. This publication, therefore, is the result of the experience of many persons. It is intended to serve both as a survey and as an analysis of United States bilateral programs of technical assistance in nursing during the years 1942 to 1966. It is also an attempt to assess, quali­ tatively, rather than quantitatively, the accomplishments of these programs. In many instances, specific answers to the questions raised will never be available. Health care and its nursing component are difficult to measure and do not lend themselves easily to qualitative analyses. Fifteen years ago, an evaluation of United States programs of health assistance in Latin America pointed out, "it is difficult, if not impossible, to assay the true and full values of such a program, which touches intimately the lives and hopes of the masses throughout a hemisphere."

vi I. THE SETTING

equipment, or industrial tools can substitute NursingStates asand it other is practiced developed today countries in the United was for an educated and healthy population, suf­ virtually unknown in many other parts of the ficiently motivated to make the most expan­ world before World War II. Until then, the sive use of these assets. Dr. Philip Lee, concept of a trained corps of professional former director of AIIYs health services has nurses, prepared to work side by side with said, "The achievement of reasonable stand­ the physician in preventive, therapeutic, and ards of health is both a prerequisite for and rehabilitative care, and providing nursing an objective of national development." services to the rich and poor, in cities and A country ridden with malaria, dengue in rural areas, and in hospitals and outlying fever, dysentery, and other debilitating dis­ health centers, was almost totallyunfamiliar eases, obviously will be impeded in its ef­ in some countries, and a dream far from forts to move into the twentieth century. realization in others. Large numbers ofpeo­ Diseases which take the lives, prematurely, ple in many areas of the world saw illness of large numbers of people deplete the human as an inevitable occurrence, to be accepted resources needed for development. Chronic fatalistically, or committed to the magical malnutrition impairs individual and collective powers of the medicine man. productivity by the apathy, low energy level, In the past twenty-four years this situation and possible intellectual retardation it may has been changing rapidly. Hampering factors cause. such as geographic isolation, certain cultural Programs of health improvement and dis­ patterns and religious beliefs, less developed ease prevention cannot achieve their objec­ economies, limited education, and the status tives without members of the various health of women are gradually being overcome. disciplines to implement them. Hospitals or With improved communications and travel health centers cannot provide effective serv­ facilities, and the "one world" concept which ices without appropriate and sufficient per­ has been steadily growing since the end of sonnel. Medical skills cannot become fully World War II, people in the less developed operational unless they are supported, com­ countries have become increasingly knowl­ plemented, and extended by skilled nursing edgeable of what life is like in modern, in­ services. dustrialized nations. Leaders are becoming In most of the countries which are trying more and more determined that their people, to improve their health conditions the primary too, shall share in the benefits of modern need has been, and still is, health manpower. living. The developing countries, old and new, Nurses, in particular, are needed in large have embarked upon amibitous programs of numbers. With a preparation that encom­ social and economic development. Assistance passes not only the skills of therapeutic care, from the United States, through such admin­ but also those of prevention, teaching, com­ istrative organizations as the Agency for In­ munications, and interpersonal relationships, ternational Development, over the past quar­ nurses are often the ones who bring the ter century, has stimulated and accelerated knowledge, practices, and benefits of modern this process of self-improvement. health care directly to those most in need of One of the richest resources of a de­ them. Their role on the health team is one veloping country is its people. No loan, no that brings them very close to the people amount of agricultural machinery, hospital themselves, so that, as WHO's Expert

1 Committee on Nursing has stated, ".... nur­ is needed in evolving such programs. In ses are the final agents of health services." some countries, the experience of USAID is too short and too recent to provide this In a developed country we can find some clues to health and perspective. nursing progress in such Obviously, nursing services are inex­ statistics as the infant mortality rate, the tricably bound to other health and welfare life span, and the incidence of various kinds services. Thus, an improvement in the com­ of preventable illness. In many of the newly munity water supply or reduction of the il­ independent countries, baseline data tor pur­ literacy rate will influence the kind of nursing poses of comparison are lacking, and facil­ services need d. Nurses ities for collecting current data are not yet working among the available. people may crease their awareness of the need for pure water and their determination The impact of measures designed to im­ to work toward that end. Standards of ad­ prove the health level of a people is neither mission to nursing schools, predicated as dramatic nor immediate. A dam, a steel they must be on an educational level appro­ mill, or a new highway is of almost instant priate to the serious, often life and death and visible benefit. The effects of a pro­ judgments which nurses must make, may gram to teach mothers healthier practices reinforce the accompanying efforts of other in feeding or caring for their children, or programs to raise the general educational a school of nursing established to produce level of the country. more and better nurses may not be visible It would be misleading to attribute pro­ for years to come. A long range perspective gress in nursing, or the lack of it, to nursing

Teaching mothers child care. 2 Child Care Demonstration. assistance alone. On the other hand, ad­ it was done, and what has been accom­ vances in nursing may well serve as one plished. How do this country's bilateral yardstick of demonstrable changes in general nursing programs operate? What are their health and social development, and should objectives? How effective has the assistance provide useful clues to the progress which is been, and what benefits, direct or indirect, being made in many countries with whom the has it produced? What factors, either within U.S. is allied through cooperative programs. the cooperative programs or within the as­ Now well into the third decade of U.S. sisted countries, have accelerated or in­ technical assistance to nursing programs in hibited the development of nursing? An many parts of the world, enough time has attempt will be made to answer these ques­ passed to look at what has been done, how tions in succeeding chapters.

3 II. BILATERAL HEALTH PROGRAMS AND TECHNICAL ASSISTANCE IN NURSING

In addition, there have been the individual Bilateral nurses and doctors who have struggled some­ times almost singlehandedly, to improve Health Programs health conditions in whatever area of a foreign country they have been located. Religious in health we missions have established hospitals, health B arey United referring, States andassistance will be throughout this centers, and nursing schools, and have em­ report, to bilateral health programs, under ployed United States nurses to develop nur­ the aegis of official United States Govern­ sing services and to train nationalpersonnel. ment agencies, undertaken at the request of, Red Cross societies have done much the and in cooperation with, the various foreign same thing, with special attention to the es­ governments. Such formal, bilateral health tablishment of nursing schools, and the im­ programming does not necessarily represent provement of systems of nursing education. the total assistance in health and nursingde­ Some private industrial establishments have velopment that has been provided by the United gone far beyond the provision of employee States, for other agencies have made their health services, and have supported health share of important contributions. manpower training and the development of The World Health Organization, since its community wide health services in the coun­ establishment in 1948, has provided a large tries in which they are located. The work of amount of assistance in the nature of funds, philanthropic foundations, such as Rocke­ advisory services, and personnel to many feller and Kellogg, cannot be overlooked. countries through their health, medical, and These organizations have, for many years, nursing improvement programs. This, too, contributed significantly to health promotion can be considered as a part of United States in the developing countries in a variety of assistance since this country contributes its ways, but primarily by financing basic or share of financial support to WHO and to other advanced professional education for health worldwide and regional agencies serving personnel. health and welfare needs: such agencies as United Nations International Children's Em­ These various national and international ergency Fund (UNICEF), United Nations Edu­ efforts have unquestionably made possible cational Scientific and Cultural Organization significant improvements in the health con­ (UNESCO), United Nations Special Fund ditions of many countries. This report, (UNSF), Expanded Technical Assistance Pro­ however, must be limited to consideration of gram (ETAP), and the Pan American Health United States bilateral health programs, Organization (PAHO). sponsored by the Agency for International

4 Development (USAID) and its predecessor From the earliest days of the IIAA to agencies, and undertaken cooperatively with the present operations of AID, one principle, the governments of the countries assisted. that of "self help," has been adhered to Such bilateral health programs had their throughout all our assistance programs. This beginnings in 1942 with the establishment principle was made a formal criterion for aid of the Institute of Inter-American Affairs in the 1961 Foreign Assistance Act. Self (IIAA) in Washington, D. C. ITAA health help not only means that the assisted coun­ personnel worked with the various Latin tries share in the costs and personnel of a American governnients in the planning, im­ given project or program; but it also requires plementation, and improvement of health and that they demonstrate, through performance, sanitation services within those countries. their intention to take the necessary steps By 1952, twenty countries in Central and to promote social and economic development. South America had received such assistance. They must also be willing to make wise use Initiated with the IIAA, UnitedStates tech­ of the assistance granted, and to mobilize nical assistance in nursing hasbeenprovided their own resources toward the same end. under a variety of administrative auspices: Without such action on the part of the coun­ The Technical Cooperation Administration, tries being assisted, long range benefits could the Mutual Security Agency, the Economic not be derived. Cooperation Administration, the Foreign Op­ Annually the USAID Mission in each erations Administration, and the International country, in cooperation with the foreign gov­ Cooperation Administration, and finally in ernment, attempts to analyze the current 1961 the Foreign Assistance Act created the situation within the country, and study the Agency for International Development. The alternative ways in which external aid can Agency (AID) referred to throughout this re­ most effectively promote development. Thus, port is the latter, and as used includes its the need for assistance in health matters is predecessor agencies. Although many of assessed in relation to needs for assistance the programs described in this publication in other fields such as education, agricul­ were initiatedby AID's predecessor agencies, ture or industry. The specific assistance for convenience they will all be referred to programs which may finally emerge are as USAID programs. agreed upon by the country and the USAID Mission, and then submitted to Agency head­ quarters. in Washington for review and ap­ proval. This approach has sometimes resulted in The Nature Of periods when health assistance hasbeencon­ sidered less essential than a strong program Technical Assistance for industrial development, or when budge­ tary or policy considerations have cut short The fundamental objective of U.S. bi­ an ongoing program. "The problem of which lateral technical assistance programs is to comes first, health or economic development, help a country with the long range develop­ is behind many uncertainties in planning. ment of institutions, services, facilities, and The fact that health is purchasable, hence personnel that are essential to its socio­ funds must be produced to buy it, is com­ .economic progress; ideally, to the point where plicated by the knowledge that healthy human these can be maintained and further develop­ resources are needed to spur economic or. ed without outside assistance. This is, social development." purposefully, a broad definition. For many Attitudes and priorities can change with a reasons, it is not always possible to continue change in U.S. personnel assigned to the coun­ assistance until a country has actually try assisted, with changes in the policies, reached the point of complete self direction. priorities, or resources of the foreign gov­ Nonetheless, this has been the ultimate goal. ernment, or with change in U.S. foreign aid While technical assistance programs nearly policy. This has sometimes accounted for the always build for the future, they attempt, at intermittent character of health assistance. the same time, to help a country meet its Within recent years, increasing emphasis more immediate needs. has been placed on health programs that are

5 an integral and interrelated part of the total Turkey to help reestablish health programs development efforts; those designed not only disrupted by the war. A beginning in tech­ to improve a country's system of health care, nical assistance in nursing was made in but which would also make a specific con­ Burma in 1951 when 5 United States nurse tribution to its social and economic de­ advisors were assigned to that country. velopment. In the same year Iran requested and was given nursing assistance. Since that time, 'U.S. bilateral health programs have tended to be concentrated in the countries of the Near East and South Asia, the Far East Technical Assistance and Africa. This has been a result of the emergence of new countries needing In Nursing and requesting help in their social and economic development, and the recogni-­ Technical assistance activities innursing tion on the part of some older, but still whici have been undertaken over the past relatively less developed countries, of twenty-four years have been numerous and their need for improved health and nursing varied, for they have been influencedby many services. factors: the level of nursing development The program of assistance in nursing has within the country; patterns of care or serv­ the same philosophic goals as all other ice that have already been established; cul­ AID programs: to find ways "through tural or economic factors; resources and money, instruments and people ... to accel­ needs; and the nature, amount, and con­ erate the changes in behavior necessary to tinuity of United States assistance. What is achieve the goals of rapid development." true for technical assistance in general is In the AID nursing programs, particular equally true for assistance in nursing in attention has been given to people. The particular. Thus, a program or project in overall objective is to promote rather than a given country may be directed toward to impose change and to do so within the certain specific objectives such as the organ­ context of the resources, needs, goals, and ization of public health nursing services in culture of each particular country. rural areas, the improvement of nursing In summary, it may be said that nursing services within the country's hospitals, orthe program emphases have often differed in establishment or strengthening of a single the various countries, and not all phases nursing education program. More frequently, of nursing development have been attacked technical assistance in nursing hasbeenpro­ simultaneously. Technical assistance in vided as part of a more general program of nursing over the past twenty-four years has health assistance within a country; one that encompassed the following goals: has social impact, and calls for the combined improvement innurs­ and coordinated efforts (1) Development or of medicine, nursing, ing services providedto people intheir sanitary engineering, and other disciplines. country's health centers and hospitals. The first ten years of technical assistance in nursing was focused largely inthewestern (2) Development or improvement of the hemisphere, in the countries of Central and system of basic nursing education South America. Before the end of the decade, within the country. however, the pendulum of United States nurs­ (3) Development or improvement of ed­ ing and health assistance was beginning to ucational programs swing to other areas. In 1944, a Public for special groups of nursing and health Health service person­ Service mission was sent to Liberia nel: midwives; in response health visitors (a to that country's request for public health help in developing health services and medical worker concentrating in the field of maternal care facilities. In 1946, a similar and childhealth); mission and auxiliary (practical) nurses. was sent to Yemen, and, in the same year, a health and rehabilitation program was (4) Development or improvement of post­ started in the Philippines. In 1947, Amer­ basic educational programs invarious ican field parties were sent to Greece and nursing fields: nursing service

6 administration, teaching of nursing, participant training. Over the years many public health nursing, clinical nursing nurses of other countries, through the AID specialties, maternal and child health, participant training program, have had the and psychiatric nursing. opportunity to study nursing in the United (5) Assistance in the development of na­ States, or elsewhere. In countries where tional standards for nursing schools nursing schools were either non-existent of all types, and for the registration or of a very substandard level, young people or licensing of nursing personnel. have been brought to this country, or an­ (6) Assistance with the establishment of other, for basic nursing preparation. More appropriate legislative and organiza­ often, however, nurses who have had their tional activities for the planning, con­ basic training in their own countries have trol, standardization, and advancement been sent for advanced study in public of nursing within the country. health nursing, nursing education, or nursing (7) Assistance with the establishment of service administration. Some of these nurses nursing as a recognized social insti­ have earned baccalaureate or higher degrees, tution at a national government level and many others have had educational pro­ through the creation of a centralized grams tailored to their individual needs, authority responsible for nursing with­ combining study and observation in educa­ in the Ministry of Health. tional and service institutions. (8) Development of national leadership Participant training is provided to develop personnel through the provision of a small corps of nurses within each coun­ advanced educational opportunities for try, prepared to assume leadership re­ selected nurses. sponsibilities in carrying on a program of nursing development. The great majority The foregoing is not intended as a sum­ of those who have had such training in the mary of specific AID assistance programs past are now holding the types of positions in nursing, but rather as a summary of the for which they were prepared. goals envisioned by the nurses working to­ In Peru, for instance, 10 nurses had the ward a given program objective. Thus, the opportunity of a year's postbasic study in nurses assigned to improve health care in public health nursing in the United States. "IX" country, through the establishment of In 1964, one of these nurses was chief a school of nursing capable of graduating nurse and another, assistant chief nurse, 20-25 nurses a year had to concern them­ within the Ministry of Health; seven were selves with practically all of the goals listed serving as chief nurses in the health centers, if they were to achieve their program ob­ and the remaining nurse was an instructor jective. in public health nursing at a national ed­ Technical assistance programs in nursing ucational center. Similarly, of 12 Iranian are usually implemented through the pro­ nurses who had been given advanced prepara­ vision of advisory services, participant train­ tion in the field of nursing education, one is ing and commodities. The advisory services consultant in nursing education in the Min­ provided by USAID nurses assigned to a istry of Health, three are directors of nursing particular country are a key factor in de­ schools, one is an assistant director, and velopment. The USAID nurse does not go the other seven are faculty members. into a country to take over its nursing Some of the nurse participants financed problems and attempt to solve them uni­ by the U.S. have received their advanced laterally. Rather, at the request of the education in countries other than the United country she is sent as an advisor to work States. The American University of Beirut, with the nurses of that country in develop­ The University of Sao Paulo in Brazil, the ing the most useful patterns for future University of Mexico, the University of the nursing development. East in the Philippines, and similar institu­ Special training opportunities are pro­ tions have served as advanced training cen­ vided for national nurses who participate ters for nurses from neighboring areas. in their country's nursing programs which Study at these so-called "third country" have been initiated or assisted by AID. facilities often have some distinct advantages. This is referred to by the Agency as The nurses studying at them have, as fellow 7 students, nurses of similar culture, lan­ benefit is being increasingly recognized in guage, and educational backgrounds. Fre­ the planning of training programs. In con­ quently, the course material is more suit­ trast to earlier years where the emphasis able to their needs than university courses was on preparation of the nurses for im­ in the United States which are geared to a mediate and specific needs, an increasing different system and stage of development. number of them are being given the op­ portunity to undertake long term educational The development of third country ed­ programs to prepare for leadership positions ucational facilities has occasionally been in nursing. an objective of the assistance program in Technical assistance often includes the nursing. U.S. funds have been granted to provision of teaching materials or demon­ expand the facilities of the American Uni­ stration equipment necessary for the accom­ versity of Beirut as a training institution plishment of nursing development goals. for many types of participants, including Some countries may not need this type nurses. The College of Nursing, in Karachi, of assistance, while others need it in varying Pakistan which serves as a center for kinds and amounts. Usually, the United study in nursing educationandadministration States and the assisted government share for Pakistani nurses, which has had U.S. in the necessary expenditures. Additional assistance since 1955, may eventually serve may be provided from other sources. to meet the needs of Iranian and Turkish help In Ecuador, nurses as well. the national government pro­ vided the building to serve as headquarters Nurses with advanced study usually return for a school of nursing newly organized with to their countries not only with new nursing USAID help. The United States helped with knowledge pertinent to the job to be done, the necessary adaptation of the building and but also with a broader concept of nursing paid for its reconstruction. The Rocke­ which should enhance their contributions to feller Foundation assisted with the initial general health development in their respec­ cost of operation and furnished some of the tive countries. There is evidence that this equipment.

School of Nursing, Ecuador. 8 In India, USAID assisted in the produc­ in nursing that would be provided under the tion of nursing audio-visual aids, and helped direct auspices of AID, itself. Thus, over finance the purchase of supplies, basic text­ the nearly ten years of assistance to Par­ books, and scientific equipment for the two aguay, the school of nursing has been re­ collegiate schools of nursing it helped to organized and is in the process of being establish. integrated within the National University of In Cambodia, in addition to providing Asuncion, so that it will provide nursing temporary housing for a newly established education at a collegiate level. Clinical school of nursing, USAID made available a teaching facilities have been improved, and 100 bed army field hospital to be used as assistance is being given to developing or­ the teaching ward of the hospital where ganized hospital nursing services. Graduate students were assigned for experience. nurses from Paraguay have been given ad­ In contrast to many other AID programs, vanced education at the University of Buf­ the investment in commodities for nursing falo, to prepare them as teachers or admin­ projects has been very modest. istrators of nursing in their own country. Occasionally, technical assistance in The emphasis throughout has been placed nursing has been provided, not by AID on leadership training. Paraguay, like so directly, but through contract by AID with many other countries, needs a group of well universities or other similar agencies and prepared nurses to provide the training and institutions. The first of such contracts supervision required by the auxiliary per­ was made in 1956 with the University of sonnel who provide the bulk of the direct Buffalo, the latter having agreed to provide nursing service in the country. medical and nursing educational services to Since that first and still continuing con­ Paraguay. Technical assistance began in tract, others have also been made. Both January, 1957 and has continued through the University of Minnesota and the Univer­ successive contracts to the present time. sity of Indiana have provided technical as­ In general, the contractee university pro­ sistance to nursing in Korea. Teachers vides the same kind of technical assistance College, Columbia University carried out

Teaching nurse teachers by demonstration. 9 an educational survey in Turkey with the assistance, unless provided by a special purpose of helping to develop the Florence project, it usually embedded both opera­ Nightingale School of Nursing in Istanbul. tionally and budgetarily within more general Catholic University of America assisted with programs of health assistance. It is certain, the development of nursing education in however, that nursing assistance has repre­ Colombia, and a contract is currently in sented only a very small proportion of force with St. Louis University for assist­ total United States expenditure for foreign ance to Ecuador. aid. Some of the funds have gone for con­ It would be interesting to know the cost struction of nursing schools, for equipment, of nursing assistance in relation to other supplies and study material, but by far technical programs. The figures are al­ the largest amount is invested in training most impossible to obtain since nursing programs and nursing advisory assistance.

10 III. PROGRAM AREAS IN NURSING

The first necessity usually has been to Public Health Nursing set in operation the needed public health services, and at the same time, train per­ sonnel to provide them. Those public health often the area in which P technicalublic Health assistanceis in nursing is first services which are established first will requested. Many developing countries have reflect the most urgent present needs. Where selected as their first goal the development nutritional diseases are prevalent, kwashior­ of a network of health centers, believing kor, for instance, special clinics may be that the best way to achieve better health established or a program of home visiting care for a people is to institute preventive inaugurated to teach the dietary practices health measures, especially for the rural that will prevent or relieve these condi­ dwellers for whom health services of any tions. In some countries, programs of kind are frequently unavailable. The USAID tuberculosis detection and control take prior­ programs directed to this end have usually ity. In others wide scale immunization pro­ been a team affair, calling for the joint grams have been launched with nurses as­ efforts of doctors, nurses, sanitary engi­ suming a large share of the responsibility neers, and health educators. for educating people as to why the inocula­ tions are needed, and organizing and carry­ These health centers usually include short ing out immunization programs. Prenatal term hospital care facilities and outpatient classes, well baby clinics, home visiting, clinics as well as preventive services. The and health teaching are all public health extent of minor or major illnesses treated nursing services which must sooner or later in the centers depends on the accessibility become available to the people if the country of the closest hospital. Nearly all of them, a higher level of health. however, provide some therapeutic services is to have The goal has been to make these serv­ for there is often no other source of medical ices available, and to persuade the people care in the vicinity. of their value and encourage them to use In some instances, a few of these centers them. In countries where a fatalistic atti­ were already in existence at the time of tude is taken toward illness, where modern initiation of USAID programs. Rarely, how­ or scientific knowledge of cause and effect ever, were there enough graduate nurses is limited or nonexistent, such ideas as to provide the necessary nursing services. vaccination to prevent illness, or regular Those who were available were likely to clinic check-ups for a healthy baby are lack any preparation in the methods or not easy to instill. Frequent epidemics of techniques of public health nursing. Exist­ communicable disease and high infant mor­ ing centers may have been staffed by un­ tality rates make it urgent to convince the trained workers with little general education, people of the value of preventive health who learned on-the-job, or perhaps, had services. They learn most effectively when some informal training from a doctor or they are able to see the results of these nurse. preventive health services - where they see 11 Home visiting.

12 Clinic check-up for a healthy baby, the flies don't stick to the eyes of children headman, soon became the with clean faces and that these children have less highlight of the week for the eye disease; that the people who had women as they sat on the floor been immunized did not get sick when cholera in customary style to sip tea ravaged the rest of the village; that the and listen to the nurse's ad­ babies who are fed high protein porridge vice. They learned about which the nurse taught gen­ their mothers to make eral home cleanliness, per­ get sick less often than those who are not. sonal and child care, simple In some countries, USAID nurses have helped nutrition, prenatal care, the to establish these first demonstration serv­ advantages of a trained, clean ices which are the forerunner of a country­ midwife, and of injuries caused wide program. by application of 'surmeh' to The establishment and fruitful use of pub­ children's eyes. Home visits lic health services call for much more than were made. Health posters just posting a notice stating that a certain were explained and left on dis­ clinic will be held on a given day. Most play, and film shows viewed often the educational approach must start on with enthusiasm. Talks on head a village level and be adapted to the ways and body lice never failed to of the people. Presented below, is the way enlist an attentive audience. one USAID nurse described a village nurs­ Village children would clamor ing program. to be first in line for head inspections. Fathers, too, "Friendly get-togethers, usu­ gradually started to attend the ally in the home of the village classes.

13 On one occasion, it was re­ are usually greatest, and here is where the ported to the nurse upon her USAID nurse, even though she may eventually weekly arrival that a woman be working with a Ministry of Health at the had fallen into a fit after her national level, can see for herself whatthese recent delivery. To care for needs are, and visualize the best way to go her, the villagers had strapped about meeting them. As she remains in one her and beaten her with a village, learning to know the people, their stick, while at the same time practices, and their requirements, she is refusing her water. They said able to develop a program fitting to the this woman' s mother had suf­ situation. Then, she can set in motion the fered from the same predica­ educational and administrative processes ment, had been allowed to rest that will make similar programs an eventual and, as a result, had died. reality for all the villages. So, they said, if her daughter At the same time that needs are being was left to rest, she would not identified and services developed, personnel survive. Happily, after much must be trained to provide them. At first, persuasion and advice, the new this may be by inservice training in public mother was given over to the health for the workers who are already em­ nurse's care, and relief was ployed. Sometimes, the USAID nurse, orher brought to her. What better national counterpart, actually recruit staff, way to describe the need and trained or untrained, for the centers. In­ true essence of the village pub­ formal, on-the-job courses may be insti­ lic health nursing program?" tuted, either for graduate nurses or auxil­ iaries, depending on which kind of worker Not all programs of public health nursing is available. Short term training programs assistance start at the village level, but of a more formal nature may be established many of them do. Here is where the needs on regional levels.

Auxiliary training.

14 With careful advanced planning, there health officers, community nurses, and saii­ may be some nurses or auxiliary nurses tarians who have been prepared to work who can be taught to teach other groups. together as a team in tackling health prob­ Through full use of the multiplier concept, lems in rural areas. Ethiopia has its tradi­ teaching one group to teach another, it has tional basic nursing schools, too, but the been possible to increase, by geometric community nurses who study at Gondar are progression, the numbers of personnel on prepared in a different way to carry out the various levels with at least a rudimentary activities for which the program was de­ knowledge of public health nursing. signed. They learn basic elements of nurs­ These activities, however, serve only to ing, midwifery, and public health practice get a public health nursing program started and how to apply them in rural communities in selected areas to meet immediate needs. in Ethiopia. This is perhaps an outstanding Equal attention must be given to long range example of tailoring assistance to meet a goals; to establish a more formal and per­ country's particular needs. manent public health nursing program, and to As public health services advance in a ensure a continuing supply of the trained country, or if they are at a more advanced personnel needed. This is where the area level to begin with, other measures may be of nursing education begins to overlap that taken to upgrade and standardize the serv­ of public health nursing. An effort is often ices performed. In one country, refresher made to include the principles and tech­ courses in public health nursing for graduate niques of public health nursing in the cur­ nurses were conducted. Regional confer­ ricula of the professional and auxiliary ences and workshops for public health nursing schools. Wherever the level of workers have often been held. In Iran, nursing development has permitted, post­ USAID nurse advisors initiated the idea of basic courses in public health nursing, some an annual public health nursing conference. on a university level, have been established. This conference, now held under the aus­ Special programs for special groups have pices of the nursing division of Iran's Min­ also had to be initiated or strengthened, istry of Health, provides inservice training depending on the patterns already in exist­ for the public health nurses from the coun­ ence in the country. Midwifery services, try's provincial health centers and helps for instance, are extensively used in most to keep them up to date on public health of the countries that have been assisted. practices which can be carried out in their This has called for the expansion and up­ own areas. grading of existing midwifery training pro­ During the slow but gradual process of grams or, sometimes, for less formal pro­ helping a country build up Its public health grams directed toward improving the prac­ nursing services, a number of national tices of the untrained, indigenous midwife. nurses will almost certainly be studying the Following a pattern originally stemming principles and techniques of this nursing from England, programs to prepare "health speciality in participant training programs. visitors" have been established. The level When they return home after study, they and content of the health visitor's education assume the responsibility for the continued vary, but these programs usually include development of public health nursing within some basic nursing knowledge, the principles their own country. The continuing advisory and techniques of preventive public health services of a USAID nurse usually is needed work, and midwifery. on a gradually diminishing basis. There is Imaginative assistance may lead to the evidence that too abrupt termination of as­ creation of an entirely new kind of program. sistance in nursing has sometimes left rela­ In Ethiopia, as part of a total program tively inexperienced nurses in a difficult geared to providing public health services situation, resulting in the loss of previously for the predominantly rural population, the acquired gains. unique Public Health College and Training Particularly evident at the time interna­ Center was established at Gondar, through tional assistance is terminated, although the cooperative efforts of AID, WHO, and necessary from the very inception of a pro­ Ethiopian doctors, nurses and sanitarians. gram of nursing assistance, is the need This institution now graduates non-physician for a centralized nursing authority to guide 15 The late Empress of Ethiopia awards a diploma to a graduate nurse

Male auxiliary nurse training

16 and foster the further development of pub­ received assistance in nursing development lic health and other nursing services. As USAID nurses have found a two level sys­ public health nursing services and educa­ tem already in operation, although per­ tional programs are gradually set in opera­ haps not too well formalized or organized: tion, the efforts of the USAID nurse and/or a small group of nurses trained in the her national counterpart may well shift from nursing schools of the country, and a large the grass roots to the ministerial level. group of auxiliary workers with little or These new nursing services and programs no training. need continuing government support in the In practically all of the assisted coun­ form of standards, controls, supervision, tries, the supply of nurses has been ex­ budget, and creation of staff positions with ceedingly small. Iraq was estimated to adequate remuneration and status. Other­ have fewer than 800 nurses to serve a wise, the wheels that have been set in motion population of six and a half million when may slow to a grinding halt. AID assis­ USAID assistance was instituted in 1953. tance in the establishment of a nursing Its one school of professional nursing pro­ division or the professional development of duced approximately 25 nurses annually. a chief nurse at the governmental level, India, at the same time, had one nurse gives some assurance that the programs for every 21,000 persons, as compared with that have been established will be maintained the U.S. ratio of 1 nurse to every 330 people. and will continue to develop and progress. Ethiopia, at the beginning of U.S. assistance in nursing in 1953, had only 19 professional nurses to serve the entire country of 20 million people. Nursing Education SCHOOLS OF NURSING In the early days of technical assistance primary emphasis was placed on the devel­ Recruitment of appropriate candidates for opment of public health nursing services of schools of professional nursing has often the kind just described. As experience called for special efforts on the part of showed that this objective called for im­ the USAID advisors and their national nurse provements in nursing education as well, colleagues. The goal has been to find can­ there has been an increasing tendency to didates who have a general educational back­ develop assistance programs directed toward ground sufficiently extensive to permit the both areas simultaneously. Sometimes the superimposition of a highly technical and stated objective of USAID has been limited responsible nursing education, and who have to improvement within the nursing educa­ the potential for leadership. Candidates tion area alone. with these qualifications are difficult to find The term "nursing education" is used in countries where educational opportunities, here in a very broad sense, covering the especially for women, are limited and where training of several categories of nursing women have traditionally held sheltered, service personnel. Nursing needs and re­ subservient positions. Male nurses are sponsibilities today range from the simple more common in many of the developing to the complex, and the development of countries than in the U.S., but as other several levels of nursing personnel is now job opportunities for men develop, and as generally recognized as the logical, appro­ the role of the nurse evolves as different priate, and economically sound way of meet­ from that of the substitute doctor, nursing ing the total nursing requirements of any in many countries is becoming more and population. more a woman's occupation. It is only within recent years that this An early necessity in establishing or fact has been accepted or recognized in the strengthening schools of professional nurs­ United States, with the utilization of pro­ ing is a well planned informational or re­ fessional nurses, practical nurses, and nurs­ cruitment campaign. Sometimes, the very es aides as members of the nursing service presence of a USAID nurse, symbolizing team. In many of the countries which have a respectable, intelligent, and educated

17 woman who has chosen nursing as a career, "subprofessional" school was established, has served as a recruitment force. How­ based on the completion of only a few years ever, the USAID nurse has had to do more of basic education. The course, preparing than be there. In many countries, she has its graduates for what might be called assisted in the development of informational middle-level responsibilities in nursing, is materials about nursing, and has worked, two years in length. The country also has formally and informally, through the min­ a group of rural midwives, prepared in istries of health and education, women's a one year course, and a few doctors and groups, and other community organizations, "medical assistants" with varying kinds of to recruit appropriate candidates. preparation. Obviously, this country does Admission requirements for nursing not have the kind of health services that schools vary from country to country, and are gradually being developed in some of sometimes, before a national standard has the other assisted countries. Nevertheless, been set, from school to school. It is the institution of this subprofessional school often possible to establish a level which of nursing, graduating approximately fifty will not rule out too many applicants and students a year, means the country has yet will provide an educational base upon a continuing supply of personnel who are which a nursing program may be built. trained to meet limited health needs. At the Itegue Menen School of Nursing in The curricula for USAID assisted nursing Asmara, Ethiopia the prerequisite for ad­ schools are based on internationally ac­ mission is a ninth grade education. In cepted standards with adaptations to a coun­ Turkey, three of the nursing schools re­ try's needs and considerable stress on pub­ quire the equivalent of a high school edu­ lic health nursing and midwifery. The cation while the other twenty-one schools decision of what the nurse should or should admit students after eight years of pre­ not be taught to do is sometimes difficult, liminary education. In some countries, the for the development of legislation defining admission requirements differ according to nurse practice usually comes at a very the sponsorship of the school. When the late stage in a country's progress. nursing program is part of a university's Another problem in some of the as­ education offerings, the requirements are, sisted countries is the matter of using of course, higher. student nurses to meet a hospital's need USAID nurse advisors have learned to for nursing service. There have been in­ cut their pattern to fit their cloth. In one stances of pressure to reduce both admis­ assisted country, the general educational sion and in-school standards, to provide level was too low to prepare students for for a larger student group to satisfy hos­ the study or safe practice of professional pital service requirements. United States nursing. Therefore, what was called a nurses will recognize this as a familiar

A graduating class

18 Demonstration for indigenous midwives picture from earlier nursing days here; civicas. In almost every country where the establishment of schools for the pur­ USAID has provided assistance in nursing pose of recruiting an inexpensive source there is some type of auxiliary or sub­ of labor, with only an apprenticeship type professional health worker, and frequently of training provided. Because of their an­ it is the auxiliary group which provides ticipation of this kind of situation, USAID most of the direct nursing care in the hos­ nurse advisors have often been able to help pitals and public health agencies. AID their national colleagues to avoid it. When nurses have assisted in the development schools are set up under government con­ of suitable educational programs for these trol for the express purpose of educating groups, and in the preparation of their teach­ nurses, there is less opportunity for student ers and supervisors. exploitation. The pattern of auxiliary nursing is ex­ tremely variable, depending on practices already existing in the country, and based SCHOOLS OF AUXILIARY NURSING on its particular needs. In some coun­ tries the schools are located in hospitals, Brazil has its visitadoras sanitarias, while in others they are in educational in­ Iran its behyars, and Nepal its swasta­ stitutions or specialized training centers. 19 Field training, Assistant Nurse Midwives

In nearly all countries the programs have graduate nurse. Thus, many countries, been formalized, admission requirements especially those in Latin America, have established, supervised learning experiences posthasic courses in public health nursing. provided, and the auxiliary nurse is recog­ In a few other countries, programs to give nized as essential in meeting the nursing graduate nurses special preparation in teach­ care needs of the population. ing or administration have been established with USAID assistance. Contributions have been made also to SPECIAL PROGRAMS the development of educational programs for the practice of midwifery. There are coun­ USAID educational efforts in most coun­ tries where most of the midwives are the tries have been directed toward the basic equivalent of the "granny" midwives who preparation of professional and auxiliary still practice in the less privileged parts nurses. Technical assistance has also been of the United States and who lack general provided for more specialized programs, education as well as special preparation in dictated by the situation in the individual midwifery. country. Recognizing the essentiality of the mid­ Noteworthy among these, perhaps, are wife group, USAID nurses have attempted, the various postbasic programs that have wherever possible, to upgrade and formal­ been established, sometimes on a university ize their preparation. Sometimes all that level, to further the competencies of the can be done, to begin with, is to work with

20 the indigenous midwives toteachthemsimple stumbling block in endeavors to establish techniques of cleanliness and somewhat safer or upgrade the nursing education system. delivery practices. In other instances, One USAID nurse advisor found a hospital formal programs for the preparation of where the wards were directed by well nurse midwives have been set up. In sev­ meaning but uninformed non-nurses. Only eral.African countries, midwifery has been one or two thermometers, face cloths, or incorporated into the basic curriculum of medicine glasses were available, for they the schools of professional nursing, an ex­ claimed, "If we put more out, people will ample of curriculum adaptation to meet ex­ steal them!" Sterility, in fact, even simple isting needs. cleanliness, was a poorly understood and poorly implemented concept. In other hos­ pitals, there were no individual patient rec­ NURSE TEACHERS ords, no written orders for drugs and treat­ ments, and no organized system to insure that each patient received even the minimal The goal of every USAID nursing edu­ care needed. cation advisor is to leave a training pro­ In the more recent years of technical gram in more competent hands than her own assistance in nursing, especially with the - those of well qualified experienced nurse continuing efforts to improve nursing schools, teachers of the country. She helps to the need for attention to hospital nursing identify potential teachers, arranges for ap­ services has been more and more recog­ propriate participant training for them, and nized, This need has also been emphasized assists with their orientation when they re­ by the physicians who have observed and turn to their country. She participates in studied in the United States and elsewhere, seminars and conferences and is often asked and who have been made aware of the im­ to teach short courses for teachers al­ portance of nursing in the total curative ready on the job. Perhaps most important plan. When a single ward has been re­ of all, she shares her own educational skills organized for nursing student practice, the with her colleagues in their day to day doctors want their patients cared for there. working relationships. As a result, some technical assistance projects have been directed to the improve­ ment of nursing services. How this is Hospital Nursing accomplished depends on the circumstances. Sometimes it is a matter of slowly reor­ Services ganizing the nursing service system (or introducing a system) and staff on a single The need for assistance in the devel­ hospital ward, This not only provides a opment of safe hospital nursing services suitable practice area for the students, but is brought sharply to the attention of the also serves as a model. Pressure from USAID nurses and their national colleagues the physicians often leads to requests for when they are confronted with the hospital the same thing in other hospital divisions. situation in which the nursing students will Some nursing service assistance projects have their nursing practice. Students, ob­ have been directed toward specific areas, viously, cannot learn howto give good nursing such as improvement of operating room care under circumstances where it is im­ practices, or the establishment of a central possible to give it, and this has proved a supply room or special care unit.

21 IV. THE USAID NURSE ADVISOR

In the past 24 years, 483 U.S. nurses sume a large share of actual operational have been employed in AID health programs responsibilities for some aspect of nursing for a total of 1244 man years. service until a national nurse has been pre­ Based on an analysis of the 45 nurses pared. Thus, in setting up public health working in 9 countries on January 1, 1966 nursing services in rural health centers, (excluding those recruited to staff hospitals a USAID nurse may serve as chief nurse in South Vietnam), a "profile" of the USAID of a health center, developing and directing nurse emerges: an individual who is 43 its nursing service, while, at the same time, years old, has had 18 years of nursing educating her national counterpart in the experience before coming to AID, and who complexities of the job. When a new school has been with the Agency for an average of nursing has been established, or an ex­ of 6 years. (The range in this last cate­ isting one upgraded, USAID nurses have fre­ gory is broad, covering periods of from quently assumed the responsibilities of direc ­ 1 year to 24 years.) tor and faculty members while national Among this group of advisors, 20 are nurses were being prepared through advanced expert in public health nursing, 17 in nursing study. There is no question but what this education, and 8 in hospital nursing ser­ manner of operation has served useful pur­ vices. While specializing in these par­ poses, but the temporary nature of such ticular areas, most of them have had some direct functioning should be stressed. Such background and experience in other nursing operational procedure has given the USAID fields as well. All of them hold Bachelor's nurse an opportunity to gain firsthand know­ degrees and 84% have Master's degrees in ledge of the existing situation and prob­ nursing or a related field. lems. It has enabled her to set up model The USAID nurses assigned to help a patterns to be duplicated elsewhere in the country in its nursing development are des­ country. Finally, her personal involvement ignated as "advisors." With the excep­ in providing needed services sometimes tion of the nurses sent to South Vietnam to under difficult circumstances, has often done provide direct nursing service for patients much to improve the image of the nurse in civilian hospitals, the primary function in the assisted country. of the nurses working in our assistance A USAID nurse assigned to Iran described programs has been to provide guidance and a trip taken by a joint United States and counsel to the national nurses or health Iranian health team to an isolated village leaders of the country who are developing, undergoing an outbreak of typhoid fever. reorganizing, or expanding that country's The route to the village carried them over nursing services. Ideally, in these bilateral a roadless plain and through a narrow, assistance programs, the aided government precipitous mountain pass. It took four­ assigns a national nurse as a counterpart teen hours to cover the seventy-five miles. to the USAID advisor, and the two work The nurse reported, "One aspect paral­ closely together. leling actual operation achievements in the There are many ways of advising; demon­ immunization program was the fact that stration, either by necessity or choice, has we were there. By 'we' I mean both the often proved most effective. Sometimes, the health department as a government agency, USAID nurse has had to temporarily as- and 'we' as United States and Iranian nurses 22 and doctors. That a team of medical work­ competence in a particular area. The reason ers was willing to endure such hardships is obvious. Rarely have the services of and hazards to reach an isolated area with the USAID nurse, regardless of her specific so few people, and to do what they could assignment, been limited to a single area. to stop the spread of illness left an im­ When one or two nurses have been assigned pression that far outlasted the effects of to a country, national nurses or health the immunizations." leaders have sought their assistance in al­ The USAID nurse advisor would not be most all matters concerned with nursing achieving her objectives if she continued di­ development. rect operational activities longer than nec­ Experience as a supervisor or consult­ essary. Her ultimate goal is not to do it ant has been considered important in the herself, but to help and demonstrate to background of all USAID advisors. No matter others how to do it. Therefore, she re­ how well versed the nurse may be in the linquishes such responsibilities as soon as field of nursing, she should also be well a national nurse has been prepared to as­ versed in the techniques of advising or sume them. Not infrequently, she serves working with others in this field; in, passing in a strictly advisory capacity from the her "know-how" to others rather than doing outset. it herself. The nature of her initial and subsequent operations has been dictated largely by the level of nursing development within a coun­ try. Where nursing is relatively underde­ Orientation veloped, it is often necessary for the USAID nurse to assume direct service or educa­ Orientation to the nature of technical tional responsibilities first. Where nursing assistance in nursing and to particular re­ is further advanced, nurses have been able sponsibilities and problems in the assigned to function on an advisory level from the countries has been extremely variable. Some beginning, guiding the country's own nurses nurses have received short term intensive as they strengthen and expand their coun­ language training before going abroad, and try's nursing services. In well planned some have not. Sometimes they have been and implemented programs of nursing as­ carefully informed about the nursing situa­ sistance, advancement can be traced in the tion in the country to which they were going, progressive transfer of responsibility from but this, too, has not always been true, USAID to national nurses. especially if they are the first USAID nurses assigned. Professional direction of the AID nursing assistance program has been limited, and there have been gaps where no nurse at all has been assigned to Agency head­ Qualifications quarters in Washington. Currently, new USAID nursing advisors Skilled technical assistance calls for a take a three weeks orientation course planned nurse with special competence in at least for all those working in AID technical as­ one of the major nursing areas: public sistance programs. In addition, theirnursing health nursing, nursing education, or hos­ orientation includes study of information pital nursing services. Occasionally, other available about nursing in the country to highly specialized abilities are required for which they are assigned, reports from their a specific assignment, such as midwifery predecessors (if there have been any), con­ preparation, or expertise in operating room sultation with AID nursing or medical per­ nursing. The nature of the specific pro­ sonnel in Washington, and visits to other gram of nursing assistance is generally re­ international agencies and to appropriate flected in the particular abilities of the on-going projects in countries with similar nurse assigned. problems. Occasionally, special intensive An effort has been made to find nurses training may be arranged. with considerable experience and maturity There is little background information in nursing in general, as well as specialized available as to the stage of development

23 of nursing in some countries. Many USAID nurses in Taiwan learned if they wanted nurses, in earlier years, had to learn by babies with diarrhea to have the large observing and by talking with the nurses, quantities of boiled and, therefore, safe doctors, and health leaders in the country water they needed, the thing to do was to about the existing systems of education prescribe weak herbal teas. These, a and service, the problems, and resources familiar remedy of the native healers, had available. the confidence of the people. Recommend­ ing their use convinced the people that the United States doctors and nurses knew what they were doing. Activities While it is possible, on a statistical basis, to draw up a "profile" of the USAID nurse, it is impossible to profile a pattern Often the nurse's first months in a new of her activities. The USAID nurse has country have been spent in learning the participated in many nursing functions si­ language in order to be able to communicate multaneously, with her varied activities cov­ with the people, and to learn about their ering a broad range of both operational and has problems and cultural patterns. She consultant services. Thus, the nurse as­ felt the need for firsthand knowledge, and signed to assist with a program of nursing depending on her particular project, she education development in one country found has spent time in visiting hospitals, nurs­ herself, at the same time, serving as tem­ in various ing schools, and health centers porary director of a new school of nursing areas of the country. Her initial activities which she had helped establish, conducting in the achievement of her program objectives inservice training programs in nursing serv­ usually cannot be spelled out in advance. ice for the staff in the hospital with which She has to work out her own approaches, the school was associated, spending some dictated by the individual situation in each time in the rural health centers in which country. students were to have practical experience, One USAID nurse, concerned with estab­ clarifying to the national nurses the sort in lishing public health nursing services of supervision and learning experiences the rural areas, spent several weeks in a vil­ students would need, assisting a very small lage where tetanus of the newborn was pre­ nucleus of national nurses with plans for valent. Cow dung, considered to have magic developing a professional nurses' associa­ new­ effects, was routinely applied to the tion, and working in a counterpart relation­ born baby's umbilicus. When she was ac­ ship with the nurse appointed to the newly cepted by the village mothers and midwives, created position of chief nurse within the try a she suggested they might want to Ministry of Health, "magic" compress she had instead of the cow dung to see if it would help keep their The problems associated with the last­ babies from stiffening up and dying. Her named activity typify a situation often en­ compresses (penicillin saturated dressings) countered in the developing countries. The worked. The mothers and midwives were particular national nurse involved was well grateful, and considerably more receptive to qualified, both by experience and education, trying her other suggestions. for the chief nurse position. However, the As this illustration indicates, USAID country was one in which women have held nurses have learned, sometimes the hard a traditionally subservient role. This na­ way, that they must proceed slowly and tional nurse found it extremely difficult to cautiously in countries where beliefs, tradi­ express an opinion among the group of men tions, and practices are different from our with whom she was working, for it ran own. They have tried to adapt their ideas contrary to her entire background. For a to the existing framework of prevailing pat­ while, the USAID nurse had to speak for terns and practices. In this instance, the her. Eventually, with guidance, suggestion, penicillin compress was not presented as and encouragement from the USAID nurse, the right way, but simply a variation of the the national nurse gained both the confidence usual practice. Similarly, both doctors and and sense of commitment necessary to speak

24 for nursing within her country's planning become familiar with the diseases prevalent group. in that area and to work out the indicated This same USAID nurse, the only one nursing care measures. assigned to the country, had also responded Many forms of teaching methods and to several calls for help in villages where materials have been used by USAID nurses. epidemics had broken out. Sometimes, as As mentioned earlier, the demonstration a member of a medical team, and some­ method on both a large and small scale times only with auxiliary nurses, she reached has proven an exceedingly valuable tool. these areas and saw to it that necessary One of these demonstrations took the form immunizations were given and precautions of a nurse sitting on a river bank with a taught. She was also working with several group of native women. She could not yet national nurses who were attempting to speak their language well, but with the aid translate English nursing texts into their of gestures and pantomime, and the use own of language. In her spare time, she was puppets, she successfully showed these caring for hospital patients, endeavoring to women ways to keep their babies healthy.

Smallpox team in action.

25 Seminars and conferences, with large and nursing leaders from the three CENTO small groups, have also served as excellent countries, Iran, Pakistan, and Turkey. Their educational techniques, not only because of closeness, geographically, and their similar the information exchanged, but because they problems and needs, enable them to profit provided an opportunity for the national from one another's experience. Turkey, nurses to know each other better, to share hesitating to raise its admission require­ each other's problems and programs, and ments to nursing schools for fear of losing to work together for improvement. Un­ applicants, was encouraged to work toward less more than a small handful of nurses this goal by Iran's comment that their ap­ instilled with the desire and the necessary plicants increased, rather than decreased, knowledge to move forward are available, with the institution of higher educational they may become discouraged or find the requirements for nursing. The greatest task ahead seemingly impossible. value of this three country conference was In 1964, USAID financed the Central derived from the stimulating face-to-face Treaty Organization (CENTO) Conference exchange of ideas, and discussion of mutual on Nursing Education, a ten day meeting of problems with colleagues from each of the

Nursing study conference.

26 other countries, as well as with nurses or within a Ministry of Health, the USAID from USAID and other participating organ­ nurse, by the kind of person she is and izations. the activities she performs, has an important The USAID nurse has served as an im­ role in influencing attitudes toward nurses portant agent for good interpersonal rela­ and the help they provide. tionships. This quality, bred from nurses' USAID nurses, over the past twenty-four early and continuing exposure to all sorts years, have traveled the 12,000 feet of rough of people in many different situations, was terrain down the Andes from La Paz to identified early in our programs of tech­ Vera Cruz, and have taken the hundreds of nical assistance. Social anthropologists, turns in the road to Katmandu in Nepal. reviewing the IIAA programs in Latin Amer­ They have battled mosquitoes, heat, dust, ica, and discussing, specifically, the neces­ and wind, and bundled themselves against sity for good interpersonal relationships deep and bone chilling mountain cold. They between the assisting and the assisted, com­ have traveled on foot, by ox cart and by jeep, mented on "thd importance of the role of and have slept on grass mats in native vil­ the trained public health nurse." "A most lages and in sleeping bags by the side of important factor making for the success of the road. They have visited villages and a public health program was seen to be the countrysides where few foreigners have ever availability of the greatest number possible been. They have struggled with languages, of public health nurses. Mothers regarded with new illnesses, with unfamiliar cultures, the nurses as real friends, not just as and with uncertain and troubled political nurses, and as their buffers against the conditions. Their end-of-tour reports al­ cold formality of the center itself." most unfailingly indicate that they have done Probably no other health discipline is all this with spirit, with enthusiasm, and so close to so many people. The physician, with dedication. Their only frustration, it especially in primitive cultures and despite would seem, lies in seeing so much more his best attempts to change this image, is to be done than they have had an opportunity often viewed with such awe and respect that to do. In every country they have left be­ it is difficult for him to establish rapport hind them at least a small group of national with those he is helping. The nurse, on the nurses equally dedicated to carrying on the other hand, is a familiar and a welcome development program that was started with figure. The people see her on their streets United States assistance. They have re­ and in their homes. They can ask her easily turned to the U.S., personally and profes­ why Juan is covered with a rash, or what sionally enriched by an experience in which they should do about Abdul's sore eyes. they have gained as much, often more, than Whether she is functioning on a village level they have given.

27 V. FACTORS INFLUENCING NURSING DEVELOPMENT

Ideas must come before tools. One of the countries, the uneducated; perhaps primitive, primary and most challenging tasks of the villagers or tribesmen, who are the ones technical advisor in any field is the develop­ most in need of health services. In each ment, not of facilities, institutions, or per­ country, of course, there is a smaller group sonnel, but of the concepts which underlie of the educated and informed. These people them. For nursing, this means that the know illness is a matter of natural causes, development of services and schools on a and they make use of available facilities for sound and continuing basis musthepreceded, care and treatment. Among themiare usually or at least accompanied, by a concept of the country's leaders who recognize the need nursing as a profession, that is, as a dis­ to make health services available to all tinct and essential type of health service, people. provided by a career corps of personnel who have been formally prepared to render However, these leaders do not necessarily this service. see nursing and nurses in the same light they are seen in the more developed coun­ In the U.S., and other industrialized tries. Their concept of nursing is more countries, this concept of nursing is simply likely to be that of personal services to the taken for granted. There is hardly anyone sick person; therefore, an appropriate oc­ to whom the word "nursing" does not im­ cupation for the servant or lower class. mediately convey a special kind of care pro­ Educated or not, many of them fail to con­ vided, and the word "nurse" the specially ceive of nursing as a thdrapeutic endeavor, trained person who renders this care. These calling for knowledge and skills essential to are concepts that need careful nurturing in the total health effort, whether it is the re­ a country whose people are unaccustomed covery of a single sick person in the hospital, to any kind of health service, and who are or the extension of preventive health serv­ inured to "survival of the fittest." ices to the population as a whole. In many of the countries AID has as­ The conception of nutsing as a random sisted, care of the sick person rarely ex­ conglomeration of various helpful services tends beyond the boundaries of the immediate to the sick, capable of bbing given by any­ family. Often, the only source of treatment one with willing hands and a warm heart, is the native practitioner or medicine man. is not unique to the developing countries. The idea of institutions where sick people It seems to represent a stage through which may be cared for, or centers where they nursing in all countries has had to pass. can learn the health practices or receive One only needs to look at England or the the immunizations that will help them stay United States of a hundred years ago and well, and of a corps of trained people to remember the "Sairey Gamps" who typified provide these and other services, develops the hospital attendants of that time: the slowly. untrained, illiterate, workhouse drudges. In These generalizations are true of the many of the developing countries, it is as great population masses of the emerging though nursing's clock has been turned back 28 a century, or more. A major objective of technical assistance in nursing is to make Role Of Women the clock move more rapidly, and to com­ press a century into far less. Those familiar with nursing history will It is difficult to write about nursing remember the horror with which Miss Night­ without mentioning Florence Nightingale who ingale's family and friends viewed her de­ first gave system and structure to nursing. termination to spend her life caring for the Unfortunately, she is remembered chiefly sick. Nursing was not for a cultured, edu­ cated woman, but an occupation for the lower for her personal sense of dedication to the of the sick and suffering. This dedication, how­ class. This same attitude is one ever, would have done little to advance stumbling blocks to nursing progress in the nursing had it not been fortified by Miss emerging countries. The widely prevalent Nightingale's equal dedication to the belief conception of nursing is that it involves no that nursing was a vocation; a separate more than the performance of unskilled health discipline with its own contribution personal services. This is compounded further with additional impeding to make to the care of the sick and the factors: promotion of health, and which called for the sheltered, subservient, or negligible careful educational preparation of selected role that has traditionally been assigned to women; the limited educational opportunities individuals. For this specific purpose, for the population in general, but women in she established a school. Her ideas were particular; and, in the countries where later distorted so that, for many years, the so-called "schools" were represented women are now pursuing professional ca­ reers, by hospitals offering little more than an the greater status that is generally apprenticeship training in order to main­ accorded professions like medicine or law. tain a supply of almost free nursing A well educated young man from one of serv­ the countries ice. Nonetheless, her basic conviction that in the Near East, studying in the United nursing was a specialized health occupa­ States as an AID training par­ -want his tion demanding specialized preparation ticipant, commented that he did not remained. fiancee at home to train for anything (she had asked his permission tostudyhairdress­ It is necessary to review this aspect of ing). He said he recognized that by our nursing history in order to fully understand standards he -was "old-fashioned," but this both the problems and objectives of nursing girl was going to be his wife and should be assistance in other nations. Nursing ad­ satisfied with making a home for him and visors must create a conception of nursing raising his children. Obviously, tradition as a special health career, and attempt to was stronger than knowledge and exposure guide its development to avoid the pitfalls to new ideas. of early nursing' development in the ad­ Another AID trainee in this country, a vanced countries: the deterioration of ed­ lawyer and accountant, when asked about ucation into an apprenticeship; and the idea nursing in his country in Southeast Asia that nursing requires no special qualifica­ said, "Well, if the -women are educationally tions or preparation. Miss Nightingale wrote, qualified, are interested 'in a health career, "It seems a commonlyconceivedidea. . .that and can afford it, they go into medicine. it requires nothing but a disappointment in Nursing is all right, but it is a second choice. love, the want of an object, a general dis­ If you need money, you go into nursing be­ gust, or incapacity for other things, to turn cause they pay you while you learn. So, a woman into a good nurse." In this coun­ our 'best' young women (he was referring try the unique contributions of nursing are to such things as social status, financial taken for granted in hospitals, health agen­ standing, and education) usually become doc­ cies, schools and industries. This same tors." He then proceeded to outline his image USAID advisors have tried to build own ideas about how girls in his country up in the assisted countries, not for the might be attracted to nursing. "Give it development of nursing per se, but because more prestige. If a girl could study nursing it is essential to the health and well-being in college, if she had some courses in what of a people. you in the United States call the liberal arts, 29 if she had to pay for her education instead considerations add further pressure for of receiving a stipend while she was train­ curative, as opposed to preventive services. ing, nursing would have more prestige." One authority in the field of international Nursing so desperately needs these health has recently stated: "The greater "best" young women; women with the abil­ the proportion of the health budget spent ities, educational background, and leader­ on curative services, the longer the delay ship potential for the responsibilities that in permanent improvement." As a corol­ will be theirs in the future. Often USAID lary to this, however, is a conclusion reached nurses have had to personally recruit or after ten years of offering primarily pre­ persuade candidates of the desirable calibre ventive health services to the citizens of to study nursing. One such nurse, who Latin American countries: "If the premise helped to establish a new school of nursing is accepted that in the long run better world in a country which had no visualization of health will come from preventive medicine, modern nursing, described the first class the fact must also be recognized that a of students as "lukewarm or doubtful that sizeable amount of curative services must this was the thing they should be doing." be available to develop the conditions es­ The majority of them finished the program, sential for a preventive program." however, went on to responsible nursing po­ In most instances, the U.S. bilateral pro­ sitions, and, thus, in themselves, served as grams of health and nursing assistance have models and an effective recruitment stimu­ been directed toward the long range goals lus for candidates of similar background. embodied in the preventive philosophy, while Again, this was a matter of demonstration. at the same time trying to meet the im­ The school now reports a greater number mediate needs of the people. It has seemed of qualified applicants than it can accept. to many USAID advisors in the health field In the first years of introducing nursing into that these curative services mustbe provided a country, much of the USAID nurses' time to win the people's confidence, and, thereby, must go into breaking down the cultural and to open the door to the institution and ac­ traditional barriers that serve as deterrents ceptance of preventive services. to nursing development. This approach has been a familiar one, since the situation differs only in degree from that which has long prevailed in the United States. The teaching of better health practices is an integral part of nursing, Prevention Versus Cure both in the hospital and public health field. Nurses have known for a long time that this People, in both underdeveloped and de­ teaching is more likely to be accepted when veloped countries, are more inclined to seek it is preceded or accompanied by a tangible medical and/or nursing attention when they service that relieves a discomfort or takes are ill, rather than using these services as care of an immediate problem. The nurse a 'means of staying well. This poses a di­ calling at a home to care for a mother and lemma in health assistance. Authorities new baby may first weigh the baby or seem to agree that the greatest yields in show the mother how to bathe him or prepare the improvement of a nation's health come his food. Then, if she needs to teach the from large scale preventive programs: tu­ mother about a diet for the diabetic husband, berculosis case finding, immunization pro­ or an immunization schedule for the baby, grams, malaria eradication, and nutrition her -advice is much more likely to fall on education. Opposed to this'idea is the prob­ receptive ears. -She has already demon­ lem of the people, themselves, towhomthese strated both her abilities and her interest. preventive measures are directed. Unaware Home visiting is an integral part of pub­ of the long-term benefits to be derived from lic health nursing and serves to break such programs, they see only their im­ down the barrier between. preventing illness mediate and urgent needs; someone is sick and treating it. In an African country, a and needs care. Governments feel the pres­ newly opened child health clinic averaged sure to relieve the immediate suffering and only 190 visits a month. The public health sickness of their populations, Humanitarian nurses spent a great deal of time visiting 30 homes during the next few years. They once she has arrived is not, of course, cared for the sick children and showed the unique to nursing. Advisors in other de­ mothers how to care for them, and they velopment areas must face it, too. explained measures to prevent the child Acceptance of any idea or service re­ from becoming ill again. In the course of quires someone on the scene whom the the home visits, the nurses learned to know people can get to know and with whom they the families, how they lived, what they ate, feel comfortable before they will take ad­ their sanitary facilities, and their tradi­ vantage of the services offered. Most fre­ tional beliefs about illness and health care. quently, the ones who need these services All this information proved exceedingly help­ are those in the' remote villages who have ful, for the nurses could then adapt their never before been reached by any kind of recommendations to conditions as they health program. Sometimes, the nurse can existed. The nurses consistently provided stay in one spot only long enough to train a combination of preventive and curative selected individuals in the village to provide services. That this intensive home visiting at least minimal health services. It is and educational campaign paid dividends is obvious that 'as better transportation and evidenced by the fact that, within a few communication facilities become available, years, average clinic attendance had jumped the nurse will be able to extend service to from the original 190 visits to 2000 a month. more communities in less time, and more extensive health services can be provided.

Geography And Transportation Language The widely scattered rural populations Some USAID nurses have been given and the lack of transportation and com­ short term, intensive training courses in munication facilities represent still another the language of the country to which they obstacle to the development of nursing serv­ have been assigned. In other instances their ices. A group of health centers may be individual language proficiencies have deter­ established in a certain province, but it mined their assignments, Whatever the may take days for a teaching or supervising situation, they are unlikely to be able to nurse, national or USAID, to get from one speak the language with any degree of fluency place to the next. If a nurse expects to when they arrive. The problem may be stay at one of the health centers for a given complicated in countries where several lan­ period, she may face the problem of living guages and a host of dialects are used. accommodations, for motels or guest houses Again, this problem is not limited to the in the vicinity are unknown. The nurse may USAID advisor in nursing, but it is par­ stay with a local family or spread her sleep­ ticularly acute in this field because the ing bag in the health center. The USAID nurse's effectiveness depends largely on nurse finds primitive living conditions an her ability to communicate with people. interesting experience and an added oppor­ Obviously, language problems will affect tunity to get to know the people and win the nursing education process. Often there their confidence. It is not always easy to are no nursing or medical textbooks avail­ find a national nurse willing to accept these able in the language of the country. Occa­ living conditions, especiallywhen her assign­ sionally, translations are supplied by the ment to a particular area may be for a United States Information Service or the considerable period of time. It represents USAID Regional Technical Aids Centers. to her no adventure, and she must be truly USAID nurse advisors may work with the dedicated, as indeed many of them are, to national nurses in translating English texts be willing to work in these remote areas into the language-used. In the process, the for months and sometimes years at a time. information often needs to be adapted to The problem of getting from one place such widely variable factors as the educa­ to another and of finding livingaccomodations. tional level of the students, the health

31 practices and facilities of the country, and whose practitioners are entitled to remunera­ its most urgent nursing care and service tion commensurate with their abilities and problems. responsibilities. In the face of the realities of the twentieth century, nurses, like every­ one else, need and expect adequate financial compensation for their services. In the developing countries, the all im­ Economics portant matter of status is seen as equivalent with salary. As a result, the matter of Will a country be able to support the nursing remuneration complicates the re­ kinds of nurses and nursing services it says cruitment problem. When salaries are low, it wants and toward which the nursing as­ fewer young women are inclined to enter sistance programs are directed? The future the nursing profession, and those who have of nursing in any country depends to a large been prepared are likely to look for em­ extent upon this matter of financial support. ployment in another country or adopt some In conversation with an ambassador to other means of livelihood. H-ow does one the United States from one of the Latin convince the recently emancipated woman, American countries, a nurse commented with the background, education and leader­ about the high quality of his country's nurs­ ship potential which nursing needs, that ing education. This country hadbeenpartner nursing is an appropriate and distinguished in one of our bilateral nursing assistance career for her when the salary she is of­ programs. Partly as a result of this, most fered is only a little better than that paid of its nursing schools are on a university to the factory workers in her- country? level. His response was immediate and These are very real problems with which vehement. "Our nursing education system many USAID nurse advisors have had to is so good that one out of every three of cope, and, more important, to interpret to our graduates is employed by the United those setting the objectives for nursing de­ States. We simply cannot pay the salaries velopment within a country. Good nursing that your country can." services and education cost money. A chal­ This situation has its parallels in other lengiig task has been to design programs countries. In one area of the world, nurses which will meet the most pressing needs are noted to move from their own country and yet remain within the scope of the coun­ to an adjacent one, and then to still another, try's ability to support. Sometimes the best, because of opportunities forbetter remunera­ according to our standards, has had to give tion. Sometimes, too, nurses prepared way to another standard which is the best through AID's Participant Training Program for a particular country, if the most urgent for positions in their own country find, upon needs of its largest number of people are their return, that the positions no longer to be met. exist. For reasons of economy, the govern­ ment has had to abolish them. It has hap­ pened that other nurse trainees, if qualified to practice in the United States or Great Government's Role Britain, may eventually elect to do so. One reason, again, is better salaries; another is There is one important difference in the their acceptance as professional health projected development of nursing in the workers. emergent countries and the way it has ac­ To a degree, this sort of situation can­ tually developed in the United States and not be prevented. In this country, many some of the European countries. The dif­ nurses are dissatisfied withsalarylevels, and ference is the matter of government spon­ they frequently change positions for others sorship and control. where the remuneration is better, Nurs­ In the United States and much of Europe, ing has traditionally been an underpaid pro­ hospitals and health agencies evolvedlargely fession. Even in the United States, nursing as voluntary, nongovernmental institutions. is sometimes viewed as a work of dedication Nursing developed, correspondingly, under and sacrifice, rather than as a profession private auspices in a spotty, uncoordinated, 32 undirected fashion. Nurses, themselves, a voice of authority can convince interested through their own professional organization officials that, for the present, it would be were the ones who eventually brought about a waste of money and effort to open the standards, improvements, and some form of school, which could result only in poorly direction and control of the systems of prepared nurses giving a poor quality of nursing education and practice. care. Instead, they might logically increase In most of the emerging countries, how­ the nursing service budget of the hospital, ever, the development of nursing and other and plan for in-service training for its nurs­ health services is largely under the control ing employees. of the government, which assumes responsi­ This example is used here to illustrate bility, social and financial, for these serv­ just how a chief nurse could function at ices. This factor of government involvement the central government level as an inter­ may either inhibit or accelerate nursing preting, planning, and developing force. She progress. needs the authority to make decisions and If the assisted government, and those set standards, and the staff to provide the within it who are responsible for nursing guidance and help necessaryfor the improve­ development, are well informed about the ment of services by the country's nurses. country's nursing needs and committed to Iran's strong Nursing Division of the Minis­ meeting them, then nursing may progress try of Health, initiated with the help of more rapidly toward its goals than it did USAID, is an example of the way govern­ in this country. With enlightened top level ment can organize at a central level to encouragement, direction, and siupport, nurs­ strengthen nursing services throughout the ing objectives can be planned, timed, and country. implemented, and a coordinating force ap­ The government, in essence, attests to plied to both services and programs. Plan­ the validity of its interest in nursing de­ ning canbe done on a regional basis, educa­ velopment by incorporating a centralized tional programs can be devised to meet nursing authority within its structure. But, specified needs, and uniform standards can governments may topple, and internal con­ be established; all of these factors contri­ ditions may change. If a situation prevails bute to steady, progressive development with where a country's government does not sup­ the most efficient use of time, personnel, port nursing as a major social institution and money. and provide for its development as an es­ Such .a state of affairs has come into sential health service to the people, then existence. only in those countries where nursing's progress is inhibited. In most of nursing has been firmly established at a the countries which AID has assisted, the central level as an essential government government is the only instrument through service and responsibility. This means which nursing can be promoted. The private nurses at this level, usually in the Ministry hospitals and agencies which so strongly of Health, interpret and direct nursing de­ influenced nursing's patterns in the U.S. are, velopment. When a new nursing school is for the most part, nonexistent. The nurses' suggested as a remedy for a provinceunder­ professional associations, which have had an supplied with nurses, it is the nurse in the important role in U.S. nursing progress, are Ministry of Health who may say, "No, we usually too recently established to have a cannot solve the problem that way. We have similar influence. In such associations, no nurses to serve as faculty members for however, lies strength for the future. USAID a new school, and we need to upgrade nurs­ nurses have frequently had some part in ing practice in the provincial hospital be­ helping with their creation and forward fore student nurses can learn there." Such movement.

33 VI. ACCOMPLISHMENTS

In the countries with which AID has worked supportive. The establishment of these in bilateral programs of technical health nursing units made it possible to do national assistance, little more than the first chapter planning for nursing care and nurse man­ of their nursing history has been written. power development, and to improve the This initial chapter, however, is an im­ quality of government nursing services. portant one sincethe patterns that have been Standards. Standards are necessary to shaped during the assistance period will insure that each nurse has the same basic have a significant influence on the future abilities. This is a fundamental tenet of development of nursing. any professional service. Otherwise, nurs­ The United States has provided technical ing services are uneven, disorganized, and assistance in nursing to forty-seven coun­ sometimes not even safe. Planning becomes tries.* In some of these, assistance has impossible and the public has no protection only recently been terminated. In a few, against malpractice and nurse quackery. it is continuing. Many others have expressed A total of 38 assisted countries now have the need for continuing aid, and there will uniform standards (admission requirements, undoubtedly be new countries to be assisted and program content and length) for their in the future. In the interest, particularly nursing schools. They keep a registration of this latter group, it is important to look list of the nurses who have attended the at what has been accomplished so far, and approved schools, and have met other re­ at the lessons which have been learned. quirements for practice. A few countries While there has never been any common have licensing examinations which their evaluative design or organized system of nurses must pass in order to become periodic analysis to facilitate the process, registered. there are, nevertheless, some tangible ac­ Nursing Education. New schools of pro­ complishments that can be counted. Some fessional nursing have been established in of the more intangible ones must, to a de­ 19 countries and those that were in existence gree, remain within the realmof speculation, prior to AID assistance have been strength­ Administration. Twenty-two countries ened, reorganized, or upgraded. Without established nursing units in their national these schools, nursing cannotprogress. They health departments during the period of are essential to a continuing and increasing AID assistance. In some countries, AID supply of nursing manpower, an overriding played a very direct role in this develop­ need in every emerging country. They are ment, with its advisor filling the post of essential, too, for the provision of nursing chief nurse in the Ministry of Health until leaders to carry on and advance the pro­ the value of such a position was demon­ grams that have been set in operation. strated and a national nurse trained and Schools for assistant nurses are equally appointed to fill it. In other countries, important. Under the supervision of pro­ this direct action was taken by the national fessional nurses, these auxiliary workers nurses themselves or by other international make up the greater part of the nursing agency advisors, and AID's role was merely staff of both hospitals and public health agencies. Many of the assisted countries *Country-by-country program resumes are recognized, earlier than was the case in included in the Annex. the United States, the need for and the value 34 Capping assistant nurse-midwives. of this subprofessional group. What they administration, or public health nursing, sometimes did not recognize, however, or by a basic school of professional nursing. were unable to implement, was the neces­ Posthasic programs in public healthnursing, sity of some type of formalized training to in particular, are now provided, under a enable the auxiliaries to make their fullest variety of auspices in many of the assisted contribution. USAID has assisted with the countries, to prepare nurses whose training development of subprofessional nurse train­ in this area has been scanty or missing, ing programs in 42 countries. or to give nurses a firmer foundation in Assistance with nursing education has this very important field. included the institution of postbasic courses and programs when feasible and indicated. It is impossible to make an accurate The College of Nursing at Karachi is an count of the number of less formal courses outstanding example of this type of effort. and training programs given by the USAID The pattern in other countries has been nurse advisors, themselves, with a view to the offering of postbasic educational pro­ meeting immediate or short term needs. grams, usually in teaching, nursing service In some instances, these programs have

35 Curriculum planning, post-basic program. continued and are now carried on by the Public Health Nursing Services. In 33 national nurses. countries, AID has assisted in the first Midwifery. This is an essential health organized government public health nursing service in many of the assisted countries, services and has developed and supported and has received United States support. a wide variety of training programs for Because midwives are prepared in so many public health nursing personnel. It is dif­ ways, a count of schools established or as­ ficult to measure final accomplishment be­ sisted would have little significance. USAID cause change in the health behavior or the nurse advisors, often in cooperation with health status of people is usually the result WHO and UNICEF, have helped with the of a combination of many efforts, not of nurs­ setting up of postbasic courses in mid­ ing alone. AID has recently conducted a wifery for graduate nurses, incorporating field study in one country to measure health midwifery education in the curriculum of change since the establishment of the first basic schools of professional nursing, and rural health centers. One important sign helping to improve the practice of the un­ of progress is that the people in many coun­ trained, indigenous midwives who serve so tries now expect and want health services many villagers. and will go any distance to avail themselves

36 of them. One Ethiopian father walked for where, at present, twenty-six million people three days with his two small sons to bring are served by about a hundred hospitals, them to an immunization clinic. staffed, for the most part, by untrained Hospital Nursing Services. Improvement workers." Unquestionably, hospital nursing in hospital nursing services is less evident services can be improved by assistance than in other areas. There have been re­ directed specifically to this goal. Equally latively few assistance projects directed so, continuing, long term improvement can toward this specific end, and, in some best be achieved by improvements in nurs­ countries, hospital care of the sick still ing education, in general, and in education leaves a great deal to be desired. One for the administration of hospital nursing USAID nurse advisor, after six years of services, in particular. helping with nursing development, sum­ Development of Nurse Leaders. An im­ marized one accomplishment, "The nursing portant part of USAID assistance in nurs­ leaders, here, are now agreed that minimum ing has been the participant training pro­ preparation for everyone who cares for grams for senior nursing personnel. To pateients should be such that: (1) no further achieve long term goals, assistance has harm or worsening of a condition occurs been directed toward setting up the ap­ to the hospital patient; and (2) the care in propriate educational and service institutions the hospital is better than the patient would in the particular countries. Obviously to receive at home." establish these on a firm basis, there is The enormity of the problem of nursing need for well prepared national nurses to development, in many countries, is attested teach, administer, and direct. Usually, out­ by the next words of the same advisor, of-country training is essential; especially "However, such a standard will take many at the beginning of technical assistance. years to put into effect in this country, The evidence indicates that when assistance has continued long enough so that the USAID nursing advisors are still in the country when the trainee returns, counterpart work­ ing relationships for a period of time add immeasurably to the benefits derived from the training program. A question that remains unanswered is that of the relative desirability of participant training in the United States as compared to training in another country. When the latter has the appropriate educational fa­ cilities, it can sometimes offer programs better geared to the participant's background and needs, and at less expense, than training in the U.S. On the other hand, participants generally prefer to come to the United States. One AID trainee, when asked what his reaction would have been had he been sent elsewhere for training responded, "I would have concluded one of two things, or maybe both: that the United States con­ sidered me an undesirable person, or that there were things here they did not want me to see." Another intangible is the value to be attached to exposure of the trainees to the way of life and the people in the United States, For the period of the survey, a total of 713 nurses have studied in the United States Hospital nursing service. on AID participant training grants and an

37 even larger number have been supported in provide a means whereby nurses throughout regional training programs in neighboring a country can work together on programs countries. The majority of these nurse of nursing development. Such associations participants are filling positions for which are also a strong force in setting standards their advanced training prepared them. and goals, in addition to serving to identify Professional Nursing Associations. nursing as an essential, self directing health Nurses' associations have been created or service within the country. They have an strengthened in 35 countries during the intangible value in the "esprit de corps" twenty-tout years of U.S. technical assist­ which they encourage and which is important ance in nursing and twenty-six of them have in countries where there are few nurses succeeded in meeting the criteria for mem­ and many obstacles to overcome. As a bership in the InternationalCouncil of Nurses, group, held together by common problems nursing's international organization. The and goals, nurses derive support from one development of these professional associa­ another for new programs which, individually, tions is extremely important, because they they might well be tempted to give up.

38 VII. AN ASSESSMENT

of the type of candidates they need, and be T nursinghe recordas aof whole,technical even thoughassistance it can­ in fully productive. not be reduced to statistical evaluation or Time is also necessary for the "tooling­ demonstrable cause and effect relationships, up" process. Neither nursing services nor is one of a high level of achievement with nursing schools can be established on any a relatively small investment of funds and sound or continuing basis without well pre­ personnel. No assisted country, so far as pared national nurses to staff anddirectthem. can be ascertained, has failed to experience Sometimes this may mean two to four years some acceleration in its nursing develop­ of participant trainingforthe national nurses, ment and improvement in the nursing serv­ followed by a period of continuing support ices provided to its people. and consultation from USAID nursing advisors Occasionally, a note of frustration ap­ as the returned participants begin to assume pears in the reports of the USAID nurses: their new responsibilities. frustration stemming from objectives not To insure continuing progress of a newly completely achieved, andfrom seeing so much established training institution or nursing more that could be done. A certain amount service, provision must be made for a con­ of this frustration must be attributed to the tinuing supPly of qualified teachers and sup­ advisor's own intense commitment to her ervisors. 4 Termination of opportunities for assigned country,- its nurses, and its still participant training with the departure of the urgent nursing needs. Talk with any nurse last AID nurse advisor and before the country back from a country where a nursing as­ could develop its own post-basic training sistance project has just been terminated, program has frequently resulted in a slow­ and you will hear more about what still re­ down or reversal of progress made during mains to be done than what has been done. the period of AID assistance. An objective survey of the record, how­ Better results have been achieved when ever, does suggest a need to spell out what the areas of public health nursing, nursing might be called "lessons learned," for the education, and hospital nursing services have benefit of those programming 'and imple­ been seen as an interrelated whole, and as­ menting bilateral programs of nursing as­ sisted concurrently. This concept of nursing sistance in the future. The first and per­ development as an integrated whole has been haps most important of these lessons is explored earlier in this report. Initial im­ that programs of nursing development take provements in public health nursing have been time and continuity of assistance. poorly sustained when the schools are not Concepts, institutions, facilities, andper­ geared to producing a continuing supply of sonnel cannot be built up within a few short prepared personnel. Similarly, nursing edu­ years. Nursing education programs, for ex­ cation services have not yielded the greatest ample, can develop only in relation to the benefits, because suitable conditions for stu­ recruitment potential among the literate dent or graduate practice do not exist. In population, and must go hand in hand with many countries, these three major fields educational development. Only when more have all been assisted, but, usually, one after and more young persons reach the general the other, and not in a coordinated way. It educational level necessary for undertaking seems reasonable to assume that simultan­ nursing study can nursing schools find enough eous attention would yield long term results, 39 and, possibly, with a smaller investment of this has affected the carefully timed de­ funds, personnel, and time. velopmental activities, and frustrated and More progress has been made toward discouraged both the national and the USAID meeting a country's overallneedsfornursing nurses involved. More important, perhaps, service when efforts have been directed is the fact that it has resulted in a waste toward developing two groups of nurses: of investment; if a constructive project is professional and auxiliary. This applies to abandoned halfway toward its goal, the gains both qualitative and quantitative progtess in made are often lost. The most successful providing nursepower. Programs directed programs have been those for which assist­ toward this two-level development have ance has been provided over a speciited num­ proved, over and over again, to represent ber of years, and withdrawn gradually as the the most economic use of available time, national government was able to assume full money, and skills, and this applies equally responsibility for their continuation. to the investment made by both the United There are indications that short term States and the home country. consultation service after termination of Have the programs of nursing assistance major programs of nursing assistance might been creatively planned to fit the individual yield substantial gains for a relatively small countries' resources, needs, and patterns? investment. In many countries, assistance On the whole, the evidence favors an affir­ ends when a country is off to a good start, mative answer, although there are some in­ and when national nurses appear to be in a stances of an effort to superimpose the nur­ position to carry on the development pro­ sing patterns of the United States. A recent grams. Problems are bound to arise, and it study directed towardthe education and train­ seems highly probable that short-term con­ ing of health personnel in less developed sultation, at regular intervals, upon request, countries suggests that educational and serv­ would contribute much to consolidating gains, ice programs need to be based on a knowl­ and accelerating future progress. This ob­ edge of the job to be done. For example, servation is based on reports from both in countries where the family routinely ac­ USAID nurse advisors and national nurses in companies the sick member to the hospital countries where assistance has been ter­ and cares for him there, the nursing school minated. curriculum may need to include how to help It would seem self-evident that planning the family help the patient; or, in countries in any field of technical assistance should be where nurses must assume such medical re­ undertaken through counsel with practitioners sponsibilities as suturing, emergency care, in that field. Yet, this has not always been or anesthesia, the curriculum should be ex­ the case in U.S. bilateral programs of nurs­ panded to include the teaching of these skills. ing assistance. Often decisions about nursing The establishment of a recognized nursing assistance are made without involving any authority,. at governmental level, has yielded nurses, either from the U.S. or from the better coverage of nursing needs, more ef'­ country. This has resultedinprojectspoorly ficient utilization of nursing resources, and suited to the country's nursing needs orpos­ a faster rate of nursing development. Such sibilities. Assistance may be offered forthe an approach also embodies a built-in mech­ establishment of a university school ofnurs­ anism for continuing advancement, essential ing when it would be more appropriate to when USAID in nursing has terminated. assist with the training of auxiliary nurses Some USAID programs in nursing as­ or to readjust existing programs and serv­ sistance have been prematurely or abruptly ices. Where nursing consultation has been discontinued. This is, of course, under­ involved from the beginning in the planning standable when internal conditions within a process, nursing programs have been more country have necessitated the withdrawal of efficiently directed toward the country's United States assistance. But it has happen­ needs and in relation to its resources. ed also that a program initially planned and Sometimes there has been no nurse con­ approved to achieve given objectives within, sultant available, even had her services say, a 6-year period, has been suddenly been sought, for there are no regional nurse terminated much earlier because of changes consultants within the USAID structure. in USAID programming priorities. Obviously, There have been periods also when there has

40 been no USAID nurse in Washington to advise part, caught up in a "revolution of rising regarding the desirability, feasibility, or expectations." No longer satisfied with means of implementing a proposed program things as they used to be, they are receptive of nursing assistance. This is ironic in to new ideas, and willing to work to achieve view of the fact that the establishment of them. .central governmental direction of nursing Progress may be erratic and uneven, but by nurses is seen as a fundamental objec­ it is progress. Governments and political tive of our assistance programs. While docu­ institutions gradually become stabilized and, mented proof is lacking, it can reasonably as they do, national planning becomes more be inferred that expert nurse consultation firmly established. Concurrent with this, services available in Washington might well the role of nurses in the overall pattern of have resulted in more constructively planned health services, and in the development of nursing assistance. human resources toward this end, is increas­ It also seems that the USAID nurse ad­ ingly clarified and strengthened. visors over the years would have profited There are many things still remaining from more readily available nursing con­ to be done in the area of nursing develop­ sultation service, either regionally or in ment. On the other hand, especially in the Washington. Expert public health nurses are countries where a modern concept of nurs­ not necessarily experts in the techniques of ing was previously nonexistent, a major technical assistance and advisory services. Many of them in the past have had to learn social revolution can scarcely be expected in the through trial and error. A more thorough span of ten, fifteen or even twenty­ four years. and specific advance orientation to the pos­ Slowly, but reasonably surely, an increasingly large number of secondary sible problems, approaches, and activities school graduates are eligible for nursing involved in technical assistance in nursing might conserve time and effort and prevent programs and restrictions on women's role are gradually disappearing; there is renewed wasted energy. governmental A final lesson is that nursing development emphasis on health assistance, is affected by the prevailing economic cli­ increased knowledge of cause and effect in disease and of methods mate. There are more than a few countries of health promotion, and the emergence of nursing as a profes­ where potential candidates decide against sion which is slowly accelerating both ec­ nursing as a career because of its poor economic rewards; where nurses, many of onomic and status incentives. All of these them prepared through United States as­ factors are accelerating the movement of nursing toward more effective service and sistance programs, elect to practice in other its ultimate purpose of better health care countries than their own; and where essential for the people. nursing agencies and schools cannot be ade­ In the United States today, the demand quately supported. This same situation pre­ for nursing services is greater than the vails, although to a considerably lesser supply of nurses to render them. This is degree, in long established countries. There not a matter are, therefore, no readily available or easy of shortage. It is the result answers to the problem, save to observe that of nurses' success in meeting so many needs in the health care field. In the words general socio-economic progress and nursing of the late Dr. Alan Gregg, former inter­ development are intimately associated and national health director of the Rockefeller that nursing assistance programs seem to perceptive observer yield greatest dividends, when they are part Foundation and a very of the health scene, "Principal among the of an integrated program of overall de­ velopmental assistance. triumphs of nursing I hold to be this: that In the course of this report, frequent you have created. a demand for your serv­ reference has been made to the various ices even before you knew them all, and then met the demand in a fashion to create still factors that either accelerate or retard the more calls upon you." process of nursing development. One posi­ tive force, however, which has not been USAID may look forward to seeing this mentioned is the fact that the persons in same pattern repeat itself in the countries the assisted countries are, for the most which it is serving today.

41 PROGRAM RESUMES

and the Ethiopian Government to establish Africa and teach in the Haile Selassie I Public Health College and Training Center for the training of teams of auxiliary healthworkers CHAD to staff rural health centers throughout the country. They assisted in the establishment AID has provided one public health nurs­ of these health centers and in supervision ing advisor for Chad since 1964. Working and evaluation of the services provided. In with three other AID school health advisors, Asmara, Eritrea, they established a model her activities have included preparation of public health nursing service and a home educational materials on 52 different health delivery program which are used as training subjects and of health curriculum guides for centers. school teachers; training and field super­ Nursing education advisors established vision of Chadian school health teams; semi­ and taught in the first nursing school in nars for teachers; and conducting a variety Eritrea, and some of its graduates are now of health education programs for school its qualified faculty members. AID re­ children, their families and their teachers. modeled and equipped the school buildings and paid operating expenses until the Government of Ethiopia could assume them. ETHIOPIA AID participant training grants enabled 22 Ethiopian nurses to receive advanced Between 1953 and 1966, twenty-nine USAID preparation in nursing in the United States, nurse advisors provided 128 years of tech­ and 43 to study in Beirut. nical assistance to nursing in Ethiopia. Nine nurses continued to serve in AM-sponsored projects beyond 1966. LIBERIA AID nurses assisted with the establish­ ment of a nursing section in the Ministry of Technical assistance in nursing was pro­ Health - now staffedbyfour Ethiopian nurses. vided to Liberia from 1943 to 1965 by 19 As active members of the Nursing Council, American nurses. In all, 55 years of service AID nurses helped to develop and implement was furnished. Prior to 1954, assistance standards for schools of nursingandfor mid­ was given by the United States Public Health wifery and dresser training programs. They Service Mission to Liberia, at the request helped develop procedures for national ex­ of the Department of State. USAID's respon­ amination and registration of all nursing, sibility for the assistance program began in midwifery and dresser workers. They aided 1954. the Ethiopian Nurses' Association during the Principal contributions made by the nurse period in which constitution and by-laws advisors during the twenty-two year period were revised to provide for organization of were: (i) Assistance to the National Public district associations. Health Service in establishing a Section of Public health nursing advisors were part Public Health Nursing; (ii) Advisory serv­ of the United States health team which col­ ices in development of apublic healthnursing laborated with the World Health Organization program, and a training program for 42 PROGRAM RESUMES (Continued)

AFRICA (Continued) Far East indigenous midwives; (iii) Assistance with BURMA the development and operation of the Tub­ man National Institute of Medical Arts; Five AID nurse advisors served a total (iv) Aid with preparation of the first na­ of 9 years in Burma between 1951 and 1953. tional examination in nursing (1952); and They helped in the establishment of a dem­ (v) Participation in activities to improve onstration and training health center, the clinical areas in the hospital used for stu-' expansion of rural public health services, dent practice. and in the training of nurses, midwives and USAID provided training grants for eleven lady health visitors. Five Burmese nurses Liberian nurses to receive advanced prep­ had United States training in public health, aration in the fields of nursing education, venereal disease and operating room nursing. nursing service administration, and public health nursing. CAMBODIA

LIBYA One USAID nursing advisor was assigned to Cambodia 1959-1961. She assisted Min­ USAID technical assistance in nursing in istry of Health officials in makinganassess­ Libya began in 1952 and extended through ment of nursing needs and resources in the 1964. U.S. personnel functioned in an op­ country, and in formulating plans for gradual erational capacity until 1963 and in an ad­ improvement of nursing education and serv­ visory role thereafter. Seven USAID nurses ice. She also worked with the people in a provided 21 years of service, concentrating small village to help them develop a clean primarily on interpreting to Government of­ water supply, sanitary privies, and a small ficials and community leaders the contribu­ health center in which the Cambodia Health tion nursing could make in a healthprogram, Services, Ministry of Health, took aninterest, developing public health nursing services AID traineeships for study of public health and giving on-the-job training topersonnelin nursing and nursing education were granted provincial health centers which were con­ to seven Cambodian nurses. structed as demonstration centers intended to emphasize disease control measures and maternal and child care; and aiding the Di­ INDONESIA rector of the Nursing School and her staff in planning and developing the basic nursing From 1951 to 1956 and from 1959 to curriculum and planning for clinical exper­ 1962, technical assistance in nursing was ience of students in government hospitals. A provided in Indonesia by threeUSAIDnurses. film made by the AID Audio-Visual Depart­ They served a total of ten years. Their ment was used extensively in attempting to principal contributions were: (1)Assistance interpret nursing to the public and to recruit with establishing a basic professional nurs­ students. Practices such as purdah, early ing school and a post-basic program in marriage, and the relatively small number of Bandung; (ii) Participation in the prepara­ girls who received high school or even an tion of faculty for the post-basic program eighth grade education hampered efforts to and in selection of nurses to receive AID build a corps of professional nurses at the financed advanced training in nursing educa­ rate needed for satisfactory implementation tion and public health nursing in the United of the nation's modest health plan. . States; and (iii) Assistance with the 43 PROGRAM RESUMES (Continued)

FAR EAST (Continued) dispensaries; and assisted in developing a dictionary of medical terms for nurses. development of a rural public health training and demonstration center in Bekasi. PHILIPPINES

Four USAID nurse advisors served in the KOREA Philippines between 1953 and 1958, providing a total of eight years of assistance. Their Immediately following the North-South primary contributions were: (i) Assistance to Korean conflict, USAID health assistance to Ministry of Health nurses in developing and the country primarily emphasized relief long-range plans for meeting nursing needs rehabilitation activities. Later emphasis was in the country; (ii) Assistance in conducting health on technical assistance to develop workshops for public health and hospital services and train personnel. nurses in leadership positions; (iii)Consulta­ Assistance in nursing was given from tion services to committees formulating ad­ 1956 to 1962 by a total of 11 AID nurses ministrative manuals for schools of nursing Their who furnished 20 years of service. and hospital nursing services; and (iv) As­ activities included serving in an advisory sistance in establishing an annual registra­ the capacity to the Korean Chief Nurse in tion of professional nurses and midwives. nursing Ministry, working as public health Thirty-six nurses received AID partici­ advisors inthe Seoul and Pusan Public Health pant grants for advanced preparation in in the Demonstration Centers, participating various nursing fields in the United States. selection of nurse participants to receive ad­ vanced preparation in public health nursing and nursing education in the United States and the Philippines, and aiding with the im­ TAIWAN provement of teaching in nursing schools. The latter was carried out under contracts Beginning in 1952, USAID nursing ad­ between AID and the Universities of Minne­ visory services were provided to both na­ sota and Indiana. tional and provincial nurse leadership groups in Taiwan. Three nurse advisors served a total of nine years between 1952 and 1961. LAOS USAID provided and equipped a school plant for the new Technical School of Nursing, One USAID nurse advisor served in Laos and reconditioned and equipped-the plant for from 1957 to 1959. Her efforts were de­ the new National Taiwan University School voted to assisting the Lao Government with of Nursing. It also provided assistance in the establishment of a sub-professional nursz. establishing the Public Health Teaching and ing school, participating in the selection of Demonstration Center on the grounds of the participants to receive midwifery trainingor University Hospital of the National Taiwan advanced preparation in nursing in Thailand University. The AID nurse was given an and Vietnam, and helping to improve the official appointment as advisor to this Center management of a 100-bed hospital inVientiane to assist with the nursing sector of the pro­ which was utilized for student practice. In gram. addition, she prepared a basic procedure AID nurses also aided with the develop­ manual fot use in the hospital; apublic health ment of two post-basic courses for training nursing manual which is used extensively supervisors and head nurses forpublic health by rural health workers who staff outlying and hospital nursing services. 44 PROGRAM RESUMES (Continued)

FAR EAST (Continued) Between 1951 and 1966, 41 USAID nurse advisors served a total-of 94 years. The chief nursing advisors for AID have given Nineteen nurses received AID participant assistance to the Ministry of Health for grants for advanced study of nursing educa­ fifteen years. They encouraged the estab­ tion and nursing service administration in the lishment of a Bureau of Nursing in the United States. Ministry, which became a reality in 1964, and have given continuous assistance to the Vietnamese Chief Nurse since her appoint­ THAILAND ment to the Bureau. Major efforts of the nursingadvisors over USAID assistance in health in Thailand the years have been concentrated on develop­ began in 1951 and has continued until the ing a corps of trained personnel for rural present. Between 1951 and 1965, nineUSAID health programs; assisting withthe organiza­ nurse advisors served for a total of 22 years. tion of health services in refugee camps; Two of the advisors worked closely with the in-service training of hospital nursing per­ Chief of the Nursing Division, Ministry of sonnel to improve the nursing care of patients; Health, on matters of organization and de­ and up-grading basic nursing education pro­ velopment of sound general nursing services grams by preparing instructors and selecting for Thailand. One of these served as nursing participants for advanced preparation in education consultant to the Division for a nursing education and service. Between 1952 period of four years. and 1966, ninety-four AID participants re­ Public health nursing advisory services ceived advanced educational preparation in were provided at the Cholburi Training Cen­ the United States. Twenty-eight of these ter to assist with development of a teach­ completed collegiate level programs inbasic ing program and field work supervision in nursing and received B.S. degrees in nursing. public health nursing and midwifery. Four USAID nurses taught at the Siriraj Hospital School of Nursing, one aided the Women's Hospital School of Nursing, and others served as advisors to the Chiengmai Nursing School faculty. Latin America AID provided participant training grants for 51 Thai nurses to obtain advanced prep­ BOLIVIA aration in nursing education and for 22 to study clinical nursing and nursing service Fifteen United States-ptiblc health nurse administration in the United States. advisors and- one midwifery advisor worked in Bolivia for a total of 32 years between 1942 and 1963. With their Bolivian counter­ VIETNAM parts, many of whom had participant training to increase their public health nursing skills, USAID technical assistance to nursing they established the first organized public in Vietnam began in 1951 before the country health nursing services in the country. A was partitioned and has continued to the Ministry of Health Nursing Division had its present. It is now the largest nursing as­ beginnings in the Public Health Servicio which sistance program AID has ever undertaken, developed a network of local public health and is expected to expand further because all services. United States nurses organized and health facilities in this war-torn country are supervised public health nursing services presently over-taxed and under-staffed. in health centers and mobile clinics, taught 45 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) Development. Through the individual and combined efforts of all these agencies, Bra­ zilian nurses were assisted in their roles nursing and midwifery auxiliaries in schools as planners, administrators, and teachers. which they helped establish and in on-the­ The reorganized National Nurses Associa­ job training programs, and helped to inte­ tion conducted the first Survey of Brazil's grate public health nursing in the general Nursing Needs and Resources. Although there nurse training schools. The 7 Bolivian nurses are still vast areas of Brazil where people who had participant training grants returned have no nursing or health services, the to their'country to assist and later to take pattern and the leadership for further de­ full responsibility for the developing nursing velopment exist. Many of the Brazilian services of their country. When USAID nurses who studied in the United States assistance to nursing was terminated, the under USAID participant training grants are public health nursing service was well es­ among the corps of national nurses well qual­ tablished, a National Nurses Association had ified to carry on the development of their been organized, the World Health Organiza­ country's nursing services and to give leader­ tion was assisting with basic nursing edu­ ship to nursing development in other Latin cation and the nuilber of nurses had increased American countries. Brazil's requests for from 1 to 100,000 people to 16 per 100,000. assistance now are for specialized consul­ However, the status of nursing and its eco­ tation in new programs and in the design nomic rewards had not improved sufficiently and conduct of operational research as a to prevent the emigration of many ofthe most basis for health services and manpower plan­ able Bolivian nurses. ning.

BRAZIL BRITISH GUIANA

USAID nursing assistance to Brazilbegan One USAID nursing advisor was assigned in 1942, and was terminated in 1963. During to British Guiana from 1962-1964 to assist that time, USAID provided 35 nurse advisors in a Survey of Nursing Services and Re­ for a total of 90 years of service, funds sources. Her recommendation for contin­ for building or remodeling nursing schools uing assistance to the country to develop and health centers, teachers' salaries, teach­ national nursing leadership was not imple­ ing materials and textbook translations, and mented by the Agency for International De­ -----shared in the operating costs of newpractical velopment. nurse schifols-and--health centers. USAID nurses assisted in the oirinization and ad­ ministration of public health nursiig-services CHILE and in the up-grading of hospital nursing care, nursing schools, and auxiliary training pro­ 'The Pan American Health Organization, grams. A post-graduate course in public the Rockefeller and Kellogg Foundations, health nursing was developed, andin-service and the Agency for International Develop­ training programs were conductedfornurses ment have all provided assistance in nursing and for both hospital and public health aux­ to Chile. Specific AID input included two iliary workers. Nursing development in USAID nursing advisors who spent a total of Brazil had substantial assistance from the 6 years assisting with-the development of Rockefeller and Kellogg Foundations and the public health nursing services in Chile. Pan American Health Organization as well Nursing services were organized in Servicio as from the Agency for International health centers, some of which served as field 46 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) in Colombia organizing public health services and public health field experience for nurs­ ing students; establishing 2 auxiliary nurse training centers for Chilean nursing stu­ training programs; organizing, teaching, and dents. A short auxiliary nurse training preparing teachers for the National School program was developed and has beencarried of Nursing; conducting short training pro­ on by national nurses. Regional and short­ grams for nurses at all levels; and assist­ term consultants assisted with plans for ing in the improvement of hospital nursing nursing school construction and with train­ services. Through a contract with Catholic ing courses and demonstration services to University, some 10 nurse specialists gave improve the quality of hospital nursing care. consultation to 6 schools of nursing. This Since 1943, a Nursing Division has been contract was terminated after 2 years by established in the Ministry of Health in mutual agreement because it was "too little Chile, legislation has been enacted to con­ trying to do too much." With AID assistance trol nursing practice, and the Chilean Nurses the National Nursing School building was Association has gained membership in the constructed and equipped, training hospital International Council of Nurses. Public wards were remodeled, textbooks translated, health nursing services have been developed, and faculty salaries paid until they could be and Chilean nursing schools have increased taken over by the school. One AID nurse in number and quality. A serious problem served as director of the school until her has been that many of the best Chilean Colombian counterpart had hadtraininginthe nurses tended to emigrate to other Latin United States. Other Colombian nurses had American countries and the United States advanced training as AID participants. The because of the low salaries paid in their framework for a modern nursing service home country. An effort has been made in existed when the AID nursing program was recent years to correct this situation. terminated, a few islands of excellence were developing with assistance from other agen­ cies, but there were only 1,100 nurses for COLOMBIA 15-1/2 million people, many of whom had no nursing care except that given by untrained USAID participated in the development auxiliaries. of nursing in Colombia from 1943 to 1963. During that time, substantial assistance was given also by the Pan American Health COSTA RICA Organization and the Rockefeller and Kellogg Foundations. In the 20-year period, a Di­ Nursing is not new in-.Costa Rica-its vision of Nursing was established in the National Nursing -School was established in Ministry of Health; legislation was enacted 1917. --Goals of the AID assistance pro­ to control nursing practice; public health gram, like those of the Pan American Health nursing services were developed; training Organization were to help the country in­ was initiated or up-graded in 6 nursing crease both the quantity and the quality of schools and 25 auxiliary training programs; nursing care. Between 1944 and 1960, 11 skilled nursing care and organization of AID nurse advisors 'worked in Costa Rica nursing services were demonstrated in se­ for a total of 16 man-years. They organized lected hospitals; 3 graduate training pro­ and supervised the nursing services in the grams were developed; corps of senior country's first 10 Servicio Public Health Colombian nurses were prepared to teach, Centers, and aided in the establishment of a plan and administer nursing services. Seven Department of Public Health Nursing in the AID nurse advisors spent a total of 26 years Ministry of Health. For a brief period, AID 47 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) Ecuadorian nurses were brought into the department and trained in public health nursing. Auxiliary nurse training programs gave limited financial and technical as­ of 3 to 8 months duration were organized sistance to the nursing school, but the long­ by USAID and PAHO nurse consultants. As­ term guidance needed for successful- insti­ sistance. was given in developing teaching tutional development was given by PAHO materials, a standard procedure manual and and the University of Kansas. . Costa Rican record forms for health centers. Consul­ nurses were given in-service andparticipant tation on curriculum development and or­ training in the organization and improve­ ganization was given to the faculty of the ment of hospital nursing services and in National School of Nursing and St. Vincent surveying hospital needs and setting up de Paul School of Nursing in Quito. Fel­ demonstration programs. Nineteen nurses lowships were provided by USAID and Rocke­ bad AID participant training in public health feller Foundation for 25 selected Ecuadorian and hospital nursing services. nurses to obtain post-basic preparation in public health nursing, nursing education or nursing service administration. In 1958, DOMINICAN REPUBLIC the Ecuadorian nurses were helped to or­ ganize a National Nurses' Association. When Two AID nursing advisors were assigned AID assistance in health was discontinued to the Dominican Republic in 1954. Because in 1963, major problems remained, Re­ the Public Health Servicio project had been cruitment of candidates for nursing schools phased out some years before, these ad­ was still a problem because limited budget visors were attached to the Education for health services made it difficultforthose Servicio. They assisted with planning for who graduated to find salaried employment. a National School of Nursing, arranged par­ The responsibility for coordination of medical ticipant training for two national nurses, care programs and public health was then conducted in-service training programs for in the Department of Health, placed within graduate nurses, and helped train 52 auxiliary the Ministry of Labor and Welfare, no nurses. The record shows that there were Nursing Division existed, 'no nurse was on the many difficulties-lack of funds and facil­ staff at the national level. In 1964, under ities, andunclear agreement about AID, PAHO, contract with AID, St. Louis University es­ and host government commitments, and AID tablished a 4-year university level nursing assistance was terminated in 1957. program at the Catholic University of Ecuador in Quito.

ECUADOR EL SALVADOR Between 1942 and 1963, 29 nurse advisors provided a total of 69 years of service in Assistance to the Ministry of Health in Ecuador. Twenty of these nurses worked the development of nursing in El Salvador as public health nursing advisors with the was provided from 1943-1964. During that Servicio; nine directed or taught in schools period, 14 USAID nurses served a total of nursing and assisted with development of 25 years. Their prirmary contribution was of organized nursing services in hospitals in the field of public health, beginning with utilized for student practice. operational support for piblic health nursing A Division of Nursing was established services and gradually changing over to con­ within the Servicio, with a USAID nurse sultation service on the national, regional, advisor serving 'as the first Chief Nurse. and local levels. For a period of time AIfl 48 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) the Roosevelt Hospital. Both agencies fur­ nished fellowships for Guatemala nurses to obtain advanced preparation in nursing edu­ supplemented the salaries of Ministry of cation, hospital nursing service, and public Health nurses working in public health. health nursing. USAID nursing advisors Twelve fellowships for post-basic prep­ helped the nurses of Guatemala to develop aration in public health nursing were granted a Nursing Council and a Nursing Associa­ to nurses who had administrative and sup­ tion. The Council, created in 1960, is ad­ ervisory responsibilities in the larger health visory to the Ministry of Health on matters centers. Assistance was given to two schools necessitating legislation to improve nursing of nursing to strengthen basic nursing edu­ service and education. When USAID as­ cation and to integrate public health nursing sistance in health was terminated in 1961, in their curricula. USAID supplied 17 par­ PAHO nursing advisors continued to provide ticipant grants to prepare faculty members consultation to the Ministry of Health and and financed construction of the National in public health nursing and professional School of Nursing in Santa Ana in 1954, and auxiliary nursing education. El Salvador has a National Nurses' As­ sociation that is not yet a member- of the International Council of Nurses. In 1962 HAITI USAID provided consultation to this Asso­ ciation on legislative and organizational mat­ In 1942 the United States Government ters. PAHO and the Kellogg Foundation have and the Government of Haiti signed an agree­ also given considerable assistance to the ment to establish a cooperative Public Health development of nursing in El Salvador. Program (Servicio) within the Haitian Min­ istry of Health. From that time until 1962, fourteen USAID nurse advisors provided 29 GUATEMALA years of service. They helped to establish and operate health centers, to prepare nurs­ USAID nursing assistance to Guatemala ing personnel to work in them, and to re­ extended from 1943-1960. Duringthis period organize and strengthen the basic nursing 13 nurse advisors served a total of 32 education program in the National School of years. Assistance was given in establishing Nursing. Nurse advisors assisted in the op­ and operating rural health centers and ma­ eration of a school to train nursing auxil­ ternal-child health clinics, setting up 5 iaries to work in rural health services, con­ mobile health units, training of public health ducted on-the-job training of all nursing personnel to work in rural areas, strengthen­ personnel in the centers, and aided in inte­ ing nursing in the public health program at grating public health nursing in the nursing the national level and strengthening the edu­ school curriculum. Eight Haitian nurses cational program of the National School of received participant training grants to study Nursing. public health nursing in the United States From 1942-1955 USAID nurses functioned and returned to assume responsibility for as Director of the National School of Nursing, the continued development of nursing serv­ then shifted to an advisory role for another ices. 4 years. PAHO nursing advisors collaborated In 1954 a nursing section was organized with them from 1952 onward, in reorganizing in the Department of Public Health. PAHO the School, revising its curriculum, provid­ nurse advisors assisted the Chief Nurse in ing in-service training for faculty, develop­ developing this Section, and together with ing auxiliary nurse training, and improving AID nurse advisors, helped the nursing the clinical areas for student practice in section develop a nationwide program for 49 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) MEXICO USAID nursing assistance in Mexico ex­ training midwives for the rural areas. By tended from 1947-1957. During that period, 1962 Haiti had 6 health centers with budgeted 5 nursing advisors served a total of 20 and filled positions for 50 public health years. Assistance was given in the or­ nurses. An AID nurse served as Director ganization of a Nursing Division in the of the National School of Nursing from Ministry of Health and in the preparation 1942 to 1951 when a Haitian nurse was ap­ of Mexican nurses to carry out its respon­ pointed to this position. Both AID and sibilities. By 1957, this Division had a PAHO provided participant training grants to Chief Nurse, 6 public health nurse instruc­ prepare nurse faculty, and by 1961, 6 full­ tors, and 2 instructors in nursing education time nurse instructors had advanced prep­ to provide consultation to the states. aration. Haiti now has 2 schools of nursing Public health nursing programs were de­ that require 11 years of basic education for veloped in selected rural areas, with Mexi­ admission. can nurses in charge; 72 nurses were granted USAID scholarships to study public health nursing in the School of Public Health in Mexico, 2 nurses to study in Chile, 2 in the HONDURAS United States, and 135 in regional centers­ in Mexico. Assistance was provided for the USAID assistance in nursing to Honduras instructors' course offered at the Division extended from 1943-1961. Five nurse ad­ of Nursing of the Graduate School of the visors worked 17 years with the Servicio, University of Mexico, starting in 1957. Forty­ helping establish health services in 7 health' three scholarships were granted to nurse districts of the country. Both AID and instructors for study in this course. USAID PAHO provided technical assistance to na­ supplemented salaries for faculty members tional nurses to up-grade the performance of and provided improvements inphysicalfacil­ auxiliary nurses in the rural health pro­ ities at the National School of Nursing. grams; and participant training for advanced At the time USAID nursing assistance was preparation in public health nursing, nursing discontinued, Mexico had a well established education, and nursing service for nurses Division of Nursing in the Ministry of Health; in key positions. a National Nurses' Association with mem­ In 1961, only one school of nursing in bership in the International Council of Nurses; the country met minimum criteria estab­ 6 post-basic programs in nursing education, lished by PAHO for inclusion in the Direc­ nursing service and public health; and 14 tory of Schools of Nursing in Latin Amer­ of its 88 professional Schools of Nursing met ica. The USAID nurse advisor assisted in minimum criteria necessary to be listed the selection of students for this school and in the Directory of Schools of Nursing in for study of basic nursing in nearby coun Latin America. During this period, as­ tries as recipients of scholarships from the sistance to nursing in Mexico was given governments of ElSalvador, Guatemala, Mex­ also by the Pan American Health Organiza­ ico, Panama, and Puerto Rico. tion and the Kellogg Foundation. The USAID health program in Honduras was terminated in 1961. Since that time, with assistance from PAHO nurse advisors, NICARAGUA a Nurses' Association has been established and a national nurse has been appointed USAID nursing assistance to Nicaragua Chief Nurse in the Ministry of Health. which began in 1943 shortlyafter the ServiCiO 50 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) United States; 7 others received grants to study nursing service administration. Staff education programs in the School was established was ended in 1963. Con­ and in-service training programs for nursing sultation services, however, were not con­ service personnel in the three hospitals were tinuous during all of these years. Twelve established; 1,800 books were supplied to the nursing advisors served a total of 15 years Nursing School library from the Regional between 1943 and 1948; 1 served from Technical AID Center in Mexico. Most 1953 to 1954; and 2 from 1960 to 1963. were in Spanish. The principal activities of the USAID ad­ visors were in the fields of public health AID nursing advisors assisted the faculty nursing and nursing education. They as­ of the School of Nursing to establish a De­ sisted in the establishment of a Section of partment of Nursing Education in the Uni­ Nursing in the Ministry of Health, acted versity of Panama in 1963. Its purpose as consultants to the Chief Nurse, and is to provide post-basic courses for grad­ took an active part in helping to improve uate nurses. health services throughout the country. In 1962 the Panamanian Nurses' Associa­ Twenty-two AID participant grants enabled tion organized and was host to the first 12 nurses to study public health nursing in International Congress of Nurses for the the United States and 10 to study in various Americas. Over 600 nurses attended. Latin American countries. In 1943, two AID nurse advisors assisted the Chief Nurse in the Ministry to establish the National School of Nursing in Managua. It is 1 of 5 PARAGUAY diploma schools in the country-the other 4 being small church-sponsored schools. Twenty-two USAID nurses served a total Both PAHO and AID have provided fellow­ of 46 years in Paraguay between 1942 and ships to prepare instructors. 1965. Principal efforts were devoted to USAID advisors helped start an auxiliary the development of public health nursing nursing program in Managua General Hos­ services in rural areas, and improvement pital and an in-service education program of basic nursing education for professional for auxiliaries in rural areas. These pro­ nurses. For 15 years, USAID nurses work­ grams were continued after AID assistance ing in the Servicio assumed responsibility was terminated. for the operation of four major health cen­ ters. They organized the nursing services, recruited and provided on-the-job training PANAMA for both professional and auxiliary nursing staff, and supervised their practice. Later, USAID assistance in nursing extended their activities shifted to development of from 1951 to 1964. During that period, services on a regional basis. A demonstra­ 7 nurse advisors gave 28 years of service tion center was created at Encarnacion, with to help up-grade the School of Nursing at organized training programs for auxiliary Santo Tomas Hospital, and to improve nurs­ personnel to staff health centers throughout ing practice at the Santos Tomas, Nicolas the region. Solano, and Psychiatric hospitals where the A nursing section was established in the student nurses obtained practical experience. Ministry of Health and Social Welfare in The Director, and 6 faculty members from 1955, Consultation to the Chief Nurse was the School of Nursing received AID partici­ provided by PAHO nursing advisors who, pant grants for advanced preparation in the in collaboration with USAID nurses, assisted 51 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) SURINAM

USAID nursing assistance to Surinam, with overall planning for development and given from 1957-1962, was provided by 2 coordination of the country's nursing and nursing advisors who served a total of 5 midwifery services. years. At the request of nursing leaders in the country, Assistance to nursing education began they focussed their .efforts on aiding with in 1952 when the Andres Barbero School the development of public health nursing of Nursing was reorganized into a three­ services in the Ministry of Health. Records available concerning AID year program accepting only high school activities are incomplete, but it graduates. From 1957 onward, through an appears that development of a demonstration health AID/University of Buffalo contract, contin­ uous nursing advisory services have been center in which personnel could be trained was given high priority. TwoSurinamnurses provided to this institution. In 1963 it be­ came a 4-year university level program and had U.S. study in public health nursing. was incorporated into the National University of Asuncion. Considerable assistance in the development of the School was provided by URUGUAY the W.K. Kellogg Foundation. USAID provided nursing assistance to Uruguay from 1944-1958. During this pe­ riod, 6 nurse advisors served a total of 12 PERU years. Four advisors assisted Servicio nurses with the development and execution Between 1942 and 1963, twelve USAID of a national public health nursing program. nurse advisors worked a total of 29 years Five demonstration health centers were de­ with the Servicio in Peru. They assisted veloped, training courses forassistantpublic with the organization of public health nurs­ health nurses instituted, and in-service train­ ing services, pioneered in the conduct of ing for graduate nurses given. Three Uru­ formal courses of training for hospital and guayan nurses received 1-year AID fellow­ public health auxiliary personnel; taught ships to study public health nursing in the public health nursing at the Rimac Health United States; 3 received 2 months' training Center--a demonstration unit established in in public health nursing in Chile. Two 1945 by the Servicio; and aided with the nursing advisors assisted the 2 professional establishment of a nursing section in the nursing schools with organization, cur­ Ministry of Health in 1951. USAID and riculum planning, development of courses, PAHO provided fellowships for national and preparation of faculty. Fourteen faculty nurses--the majority at Rimac and 11 in members from the University School of the United States. By 1963, an Institute for Nursing and 3 from the Carlos Nery School Post-Graduate Nursing was established, with of Nursing received 1-yearparticipanttrain­ PAHO assistance, under the auspices of the ing grants for study in the United States. Ministry of Health. For the first time, ad­ Uruguay's National Nursing Association vanced preparation in public health nursing, was admitted to full membership in the nursing education, and administration of International Council of Nurses in 1957. nursing services became available to na­ USAID nurse advisors worked with Associa­ tional nurses in their own country. Be­ tion members on problems of organization, tween 1961-1963, USAID nursing advisors education and legislation. Rockefeller Foun­ assisted with improvement of nursing serv­ dation and PAHO also provided training funds ices in hospitals. and advisory services to nursing in Uruguay. 52 PROGRAM RESUMES (Continued)

LATIN AMERICA (Continued) GREECE

For six years following World War II, VENEZUELA 1947-1953, five USAID nurses provided a total of 12 years technical assistance in Nursing assistance to Venezuela was nursing in Greece. During this period, confined to the field of nursing education, they assisted the Greek nurses in the Min­ Three USAID nurse advisors provided 9 istry of Health with planning for the de­ years of service between 1945-1955, to help velopment and expansion of nursing educa­ up-grade the National School of Nursing to tion and services for the country, and in the serve as a "model" for other nursing schools preparation of a nurse practice act which in the country to follow. Equipment for was put into effect in 1950. They helped the school and fellowships for faculty mem­ conduct in-service education programs for bers were contributed by the Rockefeller practical nurses in many provincial insti­ Foundation. The USAID nursing advisors tutions, taught home nursing classes, and also consulted on nursing service organiza­ worked with national public health nurses tion and assisted with the development of to organize health center activities. Four an auxiliary nurse training program. national nurses were granted fellowships to obtain preparation in public health nursing and six were sent to the United States for advanced study in nursing education.

Near East South Asia INDIA

EGYPT Over a 14-year period, 1952-1966, tech­ nical assistance in nursing was provided by USAID technical assistance in nursing 23 USAID nurses who served a total of 72 was provided from 1954 to 1957. Five years. The first nursing advisor for the nursing advisors provided 5-1/2 years of Ministry, at the request of the Deputy Di­ service before the project was prematurely rector of Health, conducted a study which terminated due to political events which ne­ identified the nursing needs of India. Rec­ cessitated removal of all USAID technicians. ommendations were made concerning activ­ ities and programs which would gradually Principal efforts were devoted to de­ help up-grade all nursing services in the velopment of the Shubra-Mant Village Health country. Demonstration Center, which was constructed by AID. Center personnel, guided by USAID USAID assistance was concentrated on: advisors, pioneered in the development of a. strengthening public health nursing health and community services for the rural services by organizing workshops and people of Egypt. The Demonstration Cen­ referesher courses in public health ter became a training field for a number of nursing for graduate nurses and lady categories of health personnel for the entire health visitors; assisting faculty mem­ country. bers to integrate public health nurs­ In-service training programs were in­ ing in the basic nursing curriculum stituted for all center nursing personnel, of several schools of nursing; train­ and post-natal visits to the homes of mothers ing instructors for the Indian Red and newborns were added to the Health cross Home Nursing Program; and Center activities. developing Nursing Manuals forpublic 53 PROGRAM RESUMES (Continued)

NEAR EAST SOUTH ASIA (Continued) serving as Ministry of Health employees in 1965. Major assistance in basic nursing educa­ health nurses, health visitors, and tion was provided by USAID nurses to the indigenous midwives; Jorjani School of Nursing in Meshed and the Nemazee School of Nursing in Shiraz. b. strengthening nursing education by helping to improve conditions in clini­ USAID nurses also aided Iranian nurse educators in the cal areas used for student practice; Ministry of Health Nursing Division in the development aiding 'with the establishment of three of a curriculum and administrative guidelines for practical collegiate nursing programs; provid­ nursing schools; orientation ing traineeships for faculty members and in-service training of new faculty to obtain advanced preparation for for these programs. In 1956 the First their responsibilities; assisting the Grand Nursing Conference was held in Tehran, sponsored National Nursing Council in making by AID. Recommendations of this Conference recommendations concerning stand­ served as a blueprint for the development of nursing ards for nursing education programs; and in Iran, and rapid progress took place in the ensuing decade. c. aiding nurse leaders to increase the i effectiveness of the national Nurses' Association in stimulating improve­ JORDAN ment in all areas of nursing. Six USAID nursing advisors provided 18 years of assistance to nursing in Jordan IRAN between 1952 and 1964. They worked coop­ eratively with personnel from other interna­ tional agencies in assisting the Ministry During the fifteen-year period from 1951­ of Health to develop a coordinated plan to 1966, USAID nurses provided a total of 128 improve health facilities in the country. years of technical assistance to nursing in Principal efforts were devoted to assist­ Iran. In all, 39 nurses assisted Iranian col­ ing Jordanian nurses in developing Health leagues with the development of public health Center programs at three Demonstration nursing services through an AID-Ministry Rural Health Centers financed jointly by of Health Cooperative organization, the im­ the United States and Jordan Government. provement and expansion of nursing education Starting with services for mothers and chil­ programs for professional and practical dren, the programs were gradually developed nurses, and the establishment of a Nursing to provide generalized health services for Division in the Ministry of Health. Begin­ the people in the community. Training ning in an operational role, theUSAIDnurses programs for various categories of health gradually changed over to serving in an personnel were developed at these centers. advisory capacity to the Iranian nurses as Fourteen nurses were provided with trainee­ they became prepared to assume respon­ ships to study public health nursing at the sibility for the various programs. American University of Beirut, and four Through AID participant grants, 23 Iran­ received advanced training in this field in ian nurses received advanced pprearation in the United States. One of the latter was nursing education, nursing service adminis­ appointed Chief Public Health Nurse in the tration, or public health nursing intheUnited Ministry of Health in 1958. States, and 49 studied at the American Uni­ In 1953, AID nurses helped establish versity of Beirut. The majority were still the Jordan School of Nursing. It was directed 54 PROGRAM RESUMES (Continued)

NEAR EAST SOUTH ASIA (Continued) Iraq was prematurely terminated at the time of the revolution in 1959.

by one of the United States nursing advisors until 1958 when Jordanian nurses demon­ ISRAEL strated their ability to assume operational responsibility. USAID nurses continued in From 1953-1957, two United States AID an advisory capacity to the faculty after that nurses provided a total of four years of time. Six Jordanian nursing faculty mem­ service in Israel. Principal assistance was bers were granted traineeships for advanced given in the fields of public health nursing preparation in the United States and four and psychiatric nursing, focussing on in­ at the American University of Beirut. In service training of graduate nurses at a addition, 14 nurses were sent abroad to demonstration health center, preparation of obtain special preparation in nursing serv­ guidelines for public health nurses, and as­ ice or ward administration, and returned to sistance to counterparts in administration help improve nursing services in clinical of nursing services. Three Israeli nurses areas used for student practice. received USAID participant grants for ad­ vanced study of public health nursing in the United States. IRAQ

During the six-year period of USAID LEBANON technical assistance to nursing in Iraq, ten public health nurses devoted the major por­ At the request of the Lebanese Govern­ tion of the 21 years they served to the de­ ment,' USAID undertook a program of tech­ velopment of maternal and child health pro­ nical assistance to nursing in 1952. Efforts grams in rural public health centers. They of the six USAID nurses who provided 18 assisted Iraq public health nurses to es­ years of service between 1952 and 1958 tablish demonstration centers, with emphasis were concentrated primarily on: on maternal and child health activities, in­ cluding home delivery services. In-service a. Assistance to the American University training of all levels of personnel and the of Beirut School of Public Health establishment of a Lady Health- Visitors in the development of a. post-basic School in Basrah were important contribu­ course in public health nursing; tions. Twelve national nurses received In-service training of the four Leban­ 1-year b. USAID participant grants to study ese nurses working in the Public public health nursing in Beirut or the United Health Department, and participation States. in the operation of several rural health From 1957-1959, one nursing education clinics; and advisor assisted the Royal Republic Hos­ pital School of Nursing in Baghdad to im­ c. -Advisory services to the Makassid prove the quality of its program. Advanced School of Nursing which was estab­ training in nursing education, in the United lished in 1954. States, was provided for seven nurse par­ ticipants; four others received special prep­ Advanced educational preparation in the to enable them to assume leadership in im­ United States, through USAID participant proving patient care. Participant training grants, was made available to seven Leban­ continued through 1961, even though USAID ese nurses. Two studied public health nurs­ technical assistance to health projects in ing; five studied nursing education. 55 PROGRAM RESUMES (Continued)

NEAR EAST SOUTH ASIA (Continued) PAKISTAN

USAID nursing advisory services to Pak­ NEPAL istan began in 1954 and extended through 1966. A total of 15 nursing advisors pro­ Between 1954 and 1966, technical assist­ vided 41 years of technical assistance dur­ ance in nursing was provied by six USAID ing that period. From 1954 to 1963 an AID nurses who served a total of 20 years in nurse served as Chief Nurse Advisor at the Nepal. They helped -with health center Ministry of Health level; in 1963 a Pakis­ development, concentrating on organization tani nurse was appointed to this position of public health nursing services 'and on­ following master's level study in nursing the-job training of health workers to staff administration in the United States on an the centers. One Nepalese nurse participant AID traineeship. received advanced preparation in public Principal efforts of the AID nurse ad­ health nursing in the United States, and visors and their counterparts were devoted nine studied public health at the University to developing the public health nursing sec­ of Beirut. The former returned to serve tions in the provincial departments of health; as Senior Nurse in the Local Health Serv­ assisting with the program for training ice Bureau, Kathmandu, and the latter are Village Aid workers; preparingpersonnelfor all working as employees of the Government 20 health centers which were constructed of Nepal. as part of a pilot project; revising the cur­ ricula of all professional nursing schools; USAID nurses assisted in the develop­ and assisting with the development of a ment of a curriculum for the Health Assis­ college of nursing for graduate nurses which tants School which was established in 1955 would prepare teaching and administrative in Kathmandu; in preparing Nepalese nurse personnel for health schools throughout East instructors; and in developing teaching ma­ and West Pakistan. The original plan for terials. This project was curtailed before the post-graduate nursing program was pre­ the planned termination date, necessitating pared cooperatively by the AID Chief Nurse a readjustment of goals. The expected guid­ Advisor and the WHO Nurse Advisor. The. ance and assistance to returning nurse College of Nursing was conducted by USAID trainees who were assigned as faculty was nursing education advisors until Pakistani not possible. nurses were prepared to assume the faculty positions. Six instructors for the College Advisory services tothe Assistant Nurse- received AID financed advanced preparation Midwifery School were similar to those in nursing education in the United States. provided for the Health Assistants School. Traineeships for advanced preparation USAID also provided adormitoryfor students in nursing education or service and in pub­ and made certain physical improvements in lic health nursing were provided for a total the training facilities. of 44 Pakistani nurses.

Nursing assistance to Bir Hospital in Kathmandu focussed on improvement of TURKEY nursing care to patients. USAID provided a traineeship for one nurse to study nurs­ Nursing advisory assistance with es­ ing service administration in the United tablishment of the Florence Nightingale States, and she returned to assume the School of Nursing in Istanbul was provided position of Director of Nursing at Bir by AID over the period 1959 to 1965. This Hospital. project, carried out under an AID/Columbia 56 PROGRAM RESUMES (Continued)

NEAR EAST SOUTH ASIA (Continued) becoming Director and Assistant Director of that institution.

University contract, involved not only the advisory services of four nurses for a total SAUDI ARABIA of four years, but advanced academic prep­ aration in the United States of 14 Turkish One public health nurse was assigned to nurse faculty members for a total of 33-1/2 the AID program in Saudi Arabia from years. One member whose study was iq the 1953-1955. She worked with Ministry of field of hospital nursing services adminis­ Health personnel in the development of a tration subsequently left the faculty and be­ rural improvement program. Local com­ came Chief Nurse, Bureau of Nursing, Min­ munity workers were given basic instruc­ istry of Health. Two others transferred to tion in maternal and child health, first aid, the University of Ankara School of Nursing, and disease control.

57 UNITED STATE 3F AMERICA I

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