The collaborative and consultative roles of nurse practitioners (NPs) have been well established in many countries, especially in the United States (US) and Canada, as NPs have become integral members of the health care team (Pulcini, J., Jelic, M., Gul, R., & Loke, A. Y., 2010). Nurse practitioners have integrated into health care systems in countries other than the United States, and their experiences have been examined in the United Kingdom, Israel, and Australia, to name a few. In this edition of Fellows Column, we provide an account of how two New York University (NYU) Meyers faculty members and adult-gerontology acute care NPs developed a new and innovative partnership with the Jakaya Kikwete Cardiac Institute (JKCI) in Dar es Salaam, Tanzania. The collaboration between NYU Meyers Global Health Initiatives and JKCI represents the first NYU partnership with a tertiary hospital system in Africa, as we expand our Global Health Initiatives and involvement into the area of critical care nursing.

The JKCI, inaugurated in 2015, is named after the immediate past President of Tanzania, Jakaya Kikwete, and specializes in the provision of comprehensive cardiac care for adult and pediatric patients in Tanzania, as well as East Africa. Since opening their doors 3 years ago, they have treated approximately 700 outpatients per week and performed approximately 100 surgeries per year, serving a critical need for acutely ill and chronically ill cardiac patients throughout the country of Tanzania. In addition to the increasing numbers of patients they have treated over the past several years, JKCI has reduced the costs of care by 65%, electing to treat cardiac patients at home instead of sending these patients to India, as was the practice before 2015.

Tanzania is the 25th poorest country in the world. Tanzania's government controls the health care system, committing only 7% of its resources to health care, well below the accepted rate of 15%. Tanzania has a national shortage of health care workers, not unlike other African countries, with 2.3 health care workers per 1,000 people, compared with 19 health care workers in Europe. More specifically, there are approximately 0.4 nurses and 0.3 clinical staff per 1,000 people (Manzi et al., 2012). Within Tanzania, there is a hierarchy of hospitals, with the top tier being consultant hospitals, followed by regional, district, health centers, and dispensaries. On average, there is one prescriber (nonphysician provider trained within Tanzania) in each primary care facility, with the workload averaging 29 patients per clinician per day in health centers and in 20 dispensaries. Within Tanzania, there is a disproportionate distribution of health care resources. Approximately 85% of the Tanzanian government's health care expenditure is given to main and central hospitals whose facilities only access 10% of the Tanzanian population, thus leaving only 15% of government health care resources to cover the remaining 90% of the Tanzanian population (Health System in Tanzania, 2014). Because of the critical shortages of nurses, there is a serious need for nurses from other countries to partner with nurses in Tanzania.

With JKCI's ascendant growth, the Executive Director sought to cultivate and develop the perioperative nursing care at the hospital and reached out to one of his academic colleagues who is the Director of health care projects for Miracle Corners of the World (MCW). Miracle Corners of the World is a nongovernmental organization based in New York City that focuses on empowering leaders through international collaborations, with active projects in Tanzania. Miracle Corners of the World's director of health care projects then reached out to our Director of Global Health Initiatives at NYU Meyers through an existing collaboration between MCW and NYU Meyers. Our tripartite collaborative consisted of JKCI's Executive Director, MCW, and NYU Meyers Global Health Initiative. This successful venture served as a roadmap and a model of what is possible and what can be accomplished with international partnerships.

After discussions among JCKI's Executive Director, MCW, and NYU Meyers Global Health Initiative about possible initiatives, we embarked on a 10-day visit to JKCI in Dar es Salaam in August 2017 with three objectives:

* To complete a comprehensive needs assessment of the nursing care within JKCI

* Meet and interview key stakeholders in nurse training both at Muhimbili University of Health and Allied Sciences (MUHAS) College of Nursing and the Ministry of Health

* Prepare a report of the needs assessment, including recommendations for improvement

Our 10-day visit included a warm welcome from our colleagues at JKCI including staff nurses, nursing administrators, and the Director of the JKCI. After a tour of the new facility, we conducted an intake assessment that included interviewing four Intensive Care Unit (ICU) nurses, one cardiothoracic surgeon, the Director of nursing, the Director of quality assurance, and the Executive Director of the JKCI. Our interview questions covered a broad range of topics including discussions of nurse to patient ratios, salaries, work schedules, mandatory overtime, physician support, policies, procedures, documentation, procedural complications, and error rates. We observed communication patterns between nurses and physicians, including hand-offs and reports of patients who were transported from the operating room to the ICU. We observed nurses performing some of their complex nursing roles within the ICU such as medication administration, physical assessments, and implementation of postoperative orders.

To obtain an additional perspective of JKCI culture and systems, we toured the emergency department and the outpatient cardiology clinic, where approximately 250 patients per day were evaluated and treated, mostly on referral from up-country regions. To gain insights into the government's allocation of nursing workforce, we met with administrators from the Ministry of Health Community Development, Gender, Elders, & Children, including the Director of Nursing and Midwifery Services. Our visit to the MUHAS, in particular the Dean of the School of Nursing, provided us with additional context regarding the preparation of future nurses who will be entering the Tanzanian health care workforce, including enrollment in nursing programs, including the diploma, baccalaureate, and graduate programs.

Overall, we learned that the nurses working in Tanzania confront many challenges when caring for cardiac patients. By the time a patient is referred from the district hospital, they have to navigate through a complex system of referral hospitals before they reach the consultant hospital. Once patients are evaluated in the hospital, their cardiac diseases have advanced and their risks for surgery have increased. The shortage of health care providers often necessitates that nurses work long hours and/or extra days in the week to maintain adequate nursing coverage.

There are few educational resources available for nurses, including limited access to books, computers, and printers. Most nurses are educationally prepared at the diploma level, with fewer than 10% of nurses having earned a baccalaureate degree and even fewer with master's degrees. The lack of educational opportunities begins early in primary and secondary schools, as students who do not elect to take science courses cannot proceed to nursing programs. Despite the difficult challenges that nurses encounter on a daily basis, their desire to learn and to provide exceptional nursing care exceeds these challenges and was inspirational.

Culturally, health care in Tanzania is very different than health care in the United States. Tanzanians confront severe poverty and experience shortages of health care providers and a scarcity of medicines and medical supplies. However, there are many similarities as well. Similar to the United States, critical care environments in Tanzania are high-risk environments, subject to wide variations in health care outcomes. Working with our nursing and medical colleagues to develop a culture of safety represents a low-tech solution to highly complicated problems that both countries can develop.

During our next visit, we will partner with the interdisciplinary team at JKCI as they work toward their goal of designation as a center of excellence, by building a culture of safety, focused on quality care, interdisciplinary communication, and an improved patient care experience and outcomes.

Acknowledgments:The authors acknowledge the support of our tripartite collaborative: Mohamed Janabi, MD, Executive Director, Jakaya Kikwete Cardiac Institute; Marion Bergman, MD, Director of Healthcare Projects at Miracle Corners of the World; and NYU Meyers Global Health Initiative.

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