The post-anesthesia care unit (PACU) was a sauna upon our arrival. The air conditioning units were disabled during the night to conserve precious energy. The team, consisting of nurses, nursing students, surgeons, midwives, gynecologists, pharmacists, and student pharmacists gathered into a large circle to join hands for a brief prayer and then run through the day’s plans. We then headed upstairs to the primary care clinic above the PACU and surgery rooms. Our task for the day involved updating the small dispensing pharmacy’s inventory and then counseling Haitian patients visiting the primary care clinic on their medications.
Back in January of last year, along with four other student pharmacists and two faculty pharmacists from the Shenandoah University Bernard J. Dunn School of Pharmacy, we participated in an interdisciplinary, medical mission trip to Jacmel, Haiti, through the Community Coalition for Haiti. Alongside other health professionals, we worked to provide needed services in a community clinic and pharmacy, a mobile clinic and pharmacy, and an operating room.
Let us continue to take you on a “day in the life,” and detail how after the trip, we reflected on steps for developing lasting changes through the inclusion of both management and employees of the health care organization in the creation of goals.
Communication barriers
The pharmacy was a small room with a desk in the middle and shelving on three walls. A refrigerator sat in the corner. Of the three shelves, one held bottles of various medications, one held ointments and creams, and one held miscellaneous items (i.e., lancets, syringes, etc.). The stock of medications in this room was scarce. Closer inspection of the shelf containing medication bottles revealed labels such as “gastrointestinal” and “cardiovascular” to indicate where the medications were intended to be kept. However, this was not how the medication bottles were organized. Instead, open bottles were kept on the shelf closest to the desk. A Haitian nurse worked to take prescriptions and dispense medications to the Haitian patients. While observing the pharmacy workflow, it became apparent that little medication counseling was typically performed and no directions were written on the packaging of the medications dispensed.
Halfway through the day, an interpreter became available to assist us in counseling patients. There was enormous difficulty in communicating with the nurse running the pharmacy prior to the interpreter’s arrival. We finally got started writing out prescription labels in Haitian Creole and discussing medications with the patients as we had been trained to do in the United States, but the nurse seemed uninterested in helping us apply these changes. In a group discussion later that evening, we came to realize we approached the situation inappropriately by not including the nurse in the work we did. When attempting to make sustainable changes, it is important to discover and realize the goals of the employees for the organization.
The next time we returned to the pharmacy, we decided to try a different approach. Through our translator, we communicated with the nurse about what we would like to do and asked for her thoughts. Still reserved with her words, she agreed to the changes we brought up. We took inventory of the medications and their expiration dates and recorded the information in an Excel spreadsheet, organized by disease state. Then, we reorganized the pharmacy.
While the shelves were already labeled by disease state, we reorganized the medications by putting them in their proper section through alphabetical order. Additionally, we pulled medications from the storage rooms that we viewed as commonly prescribed medications and placed them in the pharmacy. Although we thought the nurse agreed with our reorganization, we quickly noticed her going back to her old habits by removing medications from their respective areas and putting them on the shelf closest to her.
At the end of the day, we again reflected on our activities and ran into the issue of how to approach the situation. Even though we attempted talking with the nurse, it seemed as though we were forcing unwanted change. We came to Haiti with the goal of providing health care and sharing ideas we thought could improve their pharmacy; however, was that the case? We realized that finding out the Haitian staff’s own goals was important in order to bring about lasting change. A better approach would be to understand how they operate and what changes they would like to see, instead of just making the changes we believe should be made. For example, writing directions on dispensed medications may work in the United States but not in a country such as Haiti, where both literacy and health literacy remain enormous barriers.
How to improve the operation
Three months post-Haiti trip, we developed a plan to benefit future pharmacy teams in implementing sustainable changes on volunteer-based medical missions. Prior to arriving on site, the pharmacy team should establish communication with the organization’s person in charge to initiate the brainstorming of desired goals. This person in charge should be tasked with establishing his/her goals and the pharmacy’s goals; the individual goals of the staff running the pharmacy should also be considered. Once at the clinic, the volunteer team should meet with the person in charge and the pharmacy staff to prioritize goals and discuss resolutions.
This is a time
For pharmacy staff to bring up what they feel are the biggest areas for improvement and what realistic changes can be made during the volunteer team’s short stay. The onsite staff should be encouraged to offer their own suggestions for implementing changes first. If they struggle to find a solution, then the volunteer team may ask permission to offer their own. In order to make these changes sustainable, we suggest leaving a brief report behind for the next visiting team and listing the changes that were made, as well as the changes that have yet to be addressed. The report should also include any implementations that failed so time is not wasted by future teams in repeating those same mistakes.
During our own experience, we did not recognize the disconnect between the person in charge and the pharmacy staff at that time. We failed to address the pharmacy staff’s goals and focused solely on our own or those of the person in charge. The ultimate goal should be to consistently increase the quality of care provided to patients. This is not something that can be solely achieved in 1 week by a volunteer team. Collaboration with future teams and staff is essential.
Our hope is that our experiences will benefit those who come after us with implementing resolutions that will bring us all closer to achieving the ultimate goal.