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"The idea that the whole team's accountable was an eye-opener to them," says nurse Joanne Ehle.


An Intercontinental Exchange

Several homegrown nurses have traveled to Johns Hopkins Singapore to teach nurses there the ABC's of Western-style health care.

On her three-month tour of duty, oncology research nurse Laurie Wright discovered that family members often are involved in determining what treatment patients receive.

When Joanne Ehle discovered that Hopkins was looking for nurses willing to fly halfway around the world to be trainers at its branch in Singapore, the opportunity struck her as a no-brainer. She loved traveling, and the chance to use her nursing expertise abroad sounded like an excellent adventure. What's more, with her two daughters grown, the timing seemed perfect, and the three-month trip, a unique way to get to know a new country. "How could you not apply?" her husband asked.

The idea to send homegrown nurses to Singapore came about as Hopkins was planning to open its new medical and research hub in the tiny Southeast Asian country. The vision for Johns Hopkins Singapore was clear: to provide the same caliber of patient care that's available at home. For the fledgling oncology division, that meant recruiting a medical faculty that included some Hopkins-trained physicians. It also meant importing state-of-the-art equipment to make sure treatment would follow the same protocol as in the United States. And it required ensuring that nursing care "was a mirror of the professionalism and expertise that are standard here," says Sharon Krumm, administrator and director of nursing for Hopkins' Sidney Kimmel Comprehensive Cancer Center in East Baltimore.

Still, Krumm and other planners recognized that finding that exact brand of nursing on the other side of the world was a tall order. The role of nurses in Singapore traditionally has been to assist physicians and offer patients basic comfort. While nursing education is thorough, the job itself has long resembled more technical support than a partner in patient care. To provide the Hopkins style of medicine, the pioneering staff of the oncology department realized it would have to train nurses in Western-style health care.

But first, a nurse manager for the JHS oncology unit needed to be recruited. Monica Fulton was hired straight from her post overseeing the ambulatory cancer center in East Baltimore. After arriving in Singapore, Fulton's challenge was to hire a local nursing staff not only with experience in oncology, but interested in a new way of thinking about the profession. At age 36, Tan Jee Ling was a nurse who'd worked in several hospitals and found herself desiring a wider range of skills. "In general, nursing in Singapore is a helping role," she explains. "Very practical. We help feeding, bathing, relieving suffering. It's very busy, but it's not a role with a lot of autonomy." She joined the JHS oncology staff in 1998, impressed at once, she says, with "the opportunity to continue learning."

But how best to train the staff-most of whom had studied in Singapore and hailed from countries stretching from India to Indonesia-in the specific expectations for Hopkins nurses? Krumm and Fulton went out on a limb. They put out requests for nurses willing to travel to Singapore, set up camp for a short while, and helped orient the new trainees. Sparkling and outspoken Joanne Ehle, a critical care oncology nurse, submitted an application, stating why she thought she'd be a good candidate for an overseas stint. She found herself with a plane ticket and a task.

When Ehle arrived in Singapore in April 1999, the oncology unit was not yet open to patients. She began by showing the staff how to use new tools like high-tech IV infusion pumps (nurse manager Fulton had insisted that every piece of medical equipment on the floor match what's used in the Weinberg Building in Baltimore). Chemotherapy protocols had to parallel Hopkins methods as well: "We're more detail-oriented in determining exact doses, and we do more documenting. The nurses didn't at first expect they would have to do that for patients," Ehle recalls. She taught procedures, like how to start IVs, which in Singapore is traditionally a physician's job.

She also began to instill other expectations, namely that the nurses would take active roles in discussing patient care with doctors. "They weren't used to being part of the planning," she says. "In the U.S., we're trained to be more assertive, to double-check a physician's orders and, if we think something's not right, to speak up. The idea that the whole team's accountable was an eye-opener to them."

Three months later, Ehle's tour was up and she handed off the baton to research nurse Laurie Wright, who'd also been intrigued by the training opportunity. Wright, too, found herself with a group of nurses whose technical skills were excellent and who were eager to learn more details of oncology treatment. "We were careful not to come across as: Here come the Americans!" says Wright, who was surprised at how warmly the staff welcomed her. As patients began arriving, the nurses under her wing continued learning in weekly in-service seminars, "lunch and learn" programs, and a lecture series in which the trainees themselves chose topics and gave presentations.

In turn, the Singapore staff was eager to help Wright navigate being in a new country. "Just getting lunch was an experience," she recalls, laughing that she needed guidance to order food in the hospital cafeteria. But the JHS nurses also introduced her to aspects of medicine in a multilingual and culturally diverse society, such as how involved family members often are in determining what treatment a patient receives.

"They're usually the ones footing the bill," she says. "People would bring cash for one day's worth of chemotherapy. They would also inspect the bill and pay only for what they'd used. Here, we don't have a sense down to the item what each thing costs."

After three months, Wright turned over training responsibilities to nurse clinician Julie Yerian, who would stay for the same length of time. By the time she left, Wright says, the JHS nursing staff already had a sharper edge. "They were starting to question things, and they were working together as a team." What's more, she says, they were training each other, even in techniques like putting in IV lines. By the time Yerian came on board, she was able to assist the nurses in scheduling, staffing and balancing inpatient and outpatient care.

But to show fully how Hopkins nurses fit into the medical setting, JHS arranged for members of its staff to spend time on-site in Baltimore. In January 2002, Emily Ng and Tan Jee Ling were two who traveled together to spend a month here observing the oncology team in action. Both noted the degree of authority nurses have. In addition to being impressed with the wide range of specialized nursing careers, Ng was struck by IPOP, the inpatient/outpatient center.

"The patients were followed up closely," she says. "Typically, the workload in Singapore is heavy, and there's not a lot of time to spend with each individual." Tan concurs that she'd like to incorporate more patient communication in her work. "The nurses spent time educating patients and helping them cope. I try to do more of that now, sometimes calling people after their chemo to see how they're doing." She adds that recently a 30-year-old breast cancer patient in Singapore appreciated the time Tan offered, simply letting the woman cry.

The intercontinental exchange has been essential, Krumm notes, because of special characteristics of Hopkins cancer care. "We're unique in the U.S. in that we treat patients who would otherwise be sent to an intensive care unit. Our nursing model requires experience in critical care and in life support at the bedside." But Singapore, she adds, has educational ideas to offer in return. "The training facilities available to nurses there-from teaching space to self- paced computer training modules-are more sophisticated than anything I've seen anywhere."

The field of nursing may take time to develop a new presence in Singapore, but the exchange program has undoubtedly offered some a different perspective of the career-even in the subtlest of ways. Ehle, who came in the very beginning, remembers that some of her trainees were impressed when she explained why she dressed at home in her nursing uniform, instead of changing when she arrived at work.

"I'm proud to wear my uniform," she told them, "I'm proud for people to know I'm a nurse."

-Kate Ledger



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