It began with an idea, a dream, and a team of nurses and doctors dedicated to saving lives and providing education to other health care professionals. Our goal was to bring an organized and systematic approach of trauma care to nurses and doctors in Bulawayo, Zimbabwe, via training through the Advanced Trauma Care for Nurses (ATCN) and Advanced Trauma Life Support (ATLS) courses. Trauma is one of the largest causes of death in Africa, with the current life expectancy of 59 years of age ("Zimbabwe: Statistics on diseases, injuries, and risk factors," n.d.). The annual mortality rate in Zimbabwe is estimated at 1,775.0/100,000 people, and unintentional injuries account for 63.2% of all deaths ("Zimbabwe: Statistics on diseases, injuries, and risk factors," n.d.). The vast majority (65%) of trauma deaths occur in the poorer half of the world (low-income and lower-middle-income countries), where injury rates are the highest (Mock, 2016). Our planning process started 1 year prior to our arrival date in Africa and included working closely with the Society of Trauma Nurses (STN) as well as the American College of Surgeons (ACS) to ensure that our inaugural courses were being properly planned. The International Division of the STN and the ACS are familiar with starting programs all over the world and provided guidance and direction for each step of the process.
PLANNING
An initial component of the planning process involved gathering equipment items used during the course. The list of required equipment and supplies contained hundreds of items and included everything from gauze to airway mannequins. On September 30, 2014, after many months of planning, gathering supplies, soliciting donations, and collecting equipment, an 1,100-cubic-foot container was packed and loaded to capacity. The container of supplies, teaching equipment, electronic equipment, and medical and nursing textbooks left Knoxville, TN, for a 3-month journey to Bulawayo, Zimbabwe, 8,403 miles away. The cost to ship our container of supplies on a 3-month overseas journey to Zimbabwe was expensive but supported by a grant from the Rotary.
Educational classrooms in the United States are frequently equipped with smart boards and high-resolution screens, but third-world countries might only have chalk boards and very limited access to any technology. But thanks to newly installed technology that was completed in record time and ready for our use by Nic Rudnick (CEO of Liquid Telecom London), who stepped forward to organize direct fiber-optic broadband access at St. Philip's Nursing School. Gathering information prior to our departure also included reading about Zimbabwe's current health care system. An understanding of how a country works and what resources it has available is critically important to appropriately apply the teaching process. Items that are frequently disposable in our health care system might not even be available in other countries.
The team from the University of Tennessee Medical Center of Knoxville, TN, was led by Dr. Blaine Enderson (Professor of Trauma and Critical Care Surgery and current trauma surgeon), Dr. Lou Smith (Clinical Associate Professor Surgical Critical Care and current trauma surgeon), Dr. Philip Mitchell (Associate Medical Staff University of Tennessee Medical Center and attending staff anesthesiologist at Fort Sanders Regional Medical Center and founding member of Zimbabwe Medical Project), Dr. Roy King (Professor at the University of Tennessee Health Science Center College of Medicine and past president of the Rotary Club of Knoxville), Deborah Tuggle, RN, CEN (ATCN course director and faculty instructor), Niki Rasnake, BSN, RN, CEN (ATLS course coordinator and ATCN faculty instructor), and Theresa Day, MSN, RN (ATCN faculty instructor).
ONCE IN AFRICA
On January 31, 2015, we arrived in Africa after traveling for 31 hr and crossing several time zones. We were warmly welcomed by the staff members from the St. Philip's Convent (see Image, Supplemental Digital Content 1, available at: http://links.lww.com/JTN/A2, which shows our warm welcome to St. Philip's). We had much to accomplish during our 2-week time frame. Our agenda included an inaugural ATCN Student course, followed by an ATCN Faculty course. To complete our mission, we acted as preceptors for a second ATCN Student course taught by the new ATCN faculty members of the St. Philip's Nursing School.
Day 1 of the ATLS/ATCN Student course brought together 17 doctors and 16 nurses chosen from the region by their respective professions to attend the course. Our collaboration with ATLS Europe and ATLS South Africa included lectures provided by Dr. George Oosthuizen (Chief of Metropolitan Trauma Services, Pietermaritzburg, Kwa Zulu Natal, and President of Trauma Society of South Africa, ATLS Chair South Africa), Dr. Andrew Baker (European ATLS Director), Dr. Ian Stead (orthopedic surgeon), and Dr. Liesl Baker (anesthesiologist). The ATCN inaugural student class was composed of 16 nurses from many different provinces and districts across Zimbabwe. Some of these nurses traveled hundreds of miles at their own expense to attend the class.
During Day 1 of the course, we found the students to be engaged, interactive, and eager to master the content and skills necessary for successful completion (see Image, Supplemental Digital Content 2, available at: http://links.lww.com/JTN/A2, which shows our classroom lecture setting). English is widely spoken in Zimbabwe; however, the dialect used required careful listening and pronunciations from all parties on both sides. We found that certain words or phrases could have very different meanings or interpretations. At the conclusion of our first day of instruction, all of the students were eager to convene in the commons area and review the information from the day as well as ask questions.
Day 2 of the inaugural student class included lectures provided via Skype from staff physicians at the University of Tennessee Medical Center (see Image, Supplemental Digital Content 3, available at: http://links.lww.com/JTN/A2, which shows the Skype process being introduced). The Skype process was being piloted for the continued sustainability of ATCN as well as other collaborative educational opportunities for Zimbabwe. The end-of-course meeting included careful review of each student's performance and test scores along with discussion to identify potential ATCN faculty candidates and an ATCN course director. Ongoing measurement of the effectiveness of the trauma training we provided will be particularly difficult to obtain. Very little data from civil registration systems on morbidity or mortality is available (Lopez et al., 2002). These limitations of data also prevent the accurate measurements on the impact of trauma education.
The ATCN Faculty course was held the following week for the nine candidates chosen from the inaugural student course (see Image, Supplemental Digital Content 4, available at: http://links.lww.com/JTN/A2, which shows the faculty candidates). The nine candidates showed exemplary performance during the skills station and thoroughly enjoyed learning moulage techniques. All of the faculty candidates successfully completed the course with flying colors. Their enthusiasm for the course was professionally uplifting for all of us.
EVALUATION
Now the time had come for the second ATCN Student course that would be taught entirely by the newly trained ATCN faculty (see Image, Supplemental Digital Content 5, available at: http://links.lww.com/JTN/A2, which shows Skills Station demonstration by ATCN faculty). The course roster of students was full at 16 students. A waiting list was also established for the next course. The ATLS lectures for students of this course were provided via Skype by physicians at the University of Tennessee Medical Center in Knoxville, TN. This modality of lecture presentation worked flawlessly for the course. During our monitoring of the new ATCN faculty demonstrating and discussing the skills stations, it was very apparent that the integrity of the course would be upheld and abided by (see Image, Supplemental Digital Content 6, available at: http://links.lww.com/JTN/A2, which shows Airway Skills Station demonstration by ATCN faculty).
The nurses of Zimbabwe are extremely dedicated and proud of their profession. They ascribe to the fact that the performance of health care systems ultimately depends on the knowledge, skills, and motivation of the nurses responsible for delivering the patient care. Their vision was to achieve established standards for quality of trauma care, validated trauma education and skills training, and verification of these skills. There are many barriers to continuing education and certifications for nurses in Africa including intermittent electrical power and Internet connectivity, transportation, funding, and other family responsibilities. There are more nurses in Africa than physicians, which leaves the nurses practicing autonomously most of the time.
After the inaugural training in 2015, the first independent ATCN course was held in Zimbabwe in March 2016. Sixteen students successfully completed an ATCN course, with Zimbabwe ATCN faculty using Skype for all of the ATLS lectures given real-time at the University of Tennessee Medical Center to the St. Philip's School of Nursing (see Image, Supplemental Digital Content 7, available at: http://links.lww.com/JTN/A2, which shows ATCN faculty in Zimbabwe and Tennessee). The 7-hr time difference between Knoxville Tennessee and Zimbabwe posed no problems whatsoever to the ATCN faculty in Zimbabwe and the students attending the course. Our next ATCN course with St. Philip's via Skype had a full roster of 16 students and was held in September 2016.
One aspect of planning that we underestimated was the professional licensure verification process by the multiple levels of nursing governing bodies in Zimbabwe. Our credentials and licensure status, as well as the course content, were reviewed over the course of many months. There are many layers of governing bodies, all of which may require their own documentation and verification process. We were ultimately formally recognized and approved for the educational training we provided. Continuing education for health care professionals in the United States is readily available and affordable. This is not the case in many third-world countries.
CONCLUSION
Bringing ATCN and ATLS Student and Faculty courses to Zimbabwe and ensuring its sustainability continues to be a priority for our team. St. Philip's School of Nursing in Bulawayo has been given certification by the Zimbabwe Nursing Council as the official National Nurse Trauma Training Center for ATCN and is currently the only such center in Africa. In an e-mail from the Director of Nursing at the Zimbabwe Mater Dei Hospital, Maureen Jameison expressed, "Thank you for helping us make our dreams come true" (see Image, Supplemental Digital Content 8, available at: http://links.lww.com/JTN/A2, which shows ATCN faculty from St. Philip's and University of Tennessee Medical Center).
This endeavor would not have been a success without many thanks to those who provided behind-the-scenes assistance. The Rotary International, the Knoxville Rotary Club, and the Rotary Foundation provided grant and financial support. The collaborative alliance of the STN and the ACS in partnership with ATLS South Africa was also invaluable with their guidance and support.
KEY POINTS
* Successfully taught the first ever ATLS/ATCN courses in Africa. ATLS has been established in South Africa since 1992, Nigeria in 2010, Saudi Arabia in 1991, Israel in 1990, and Egypt in 2011. Providing the education and skills to deliver an organized and systematic process of trauma care to Bulawayo, Zimbabwe, a third-world country where this concept did not exist. Trauma is one of the leading causes of death in Africa, with ultimate goal is to reduce morbidity and mortality to patients with traumatic injuries.
* A crucial goal of this endeavor included continued sustainability by identifying instructors and providing faculty training while using teleconference between two counties more than 8,000 miles apart from each other.
* St. Philip's School of Nursing in Bulawayo has been given certification by the Zimbabwe Nursing Council as the official National Nurse Trauma Training Center for ATCN and is currently the only such center in Africa. This acknowledgment by the Zimbabwe Nursing Council has opened the door for educational opportunities for all of Africa.
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