NR 561 Week 7 Global Health Ethics Analysis Example

Ethics Analysis: A U.S. Nursing School's Clinical Immersion at a District Hospital in Sierra Leone, What Declining It Would Have Cost the Hospital, and Where the Benefits Went

Student Name

College of Nursing, Chamberlain University

NR 561: Addressing Global Health Disparities

Instructor Name

Month Day, Year

Ethics Analysis: A U.S. Nursing School's Clinical Immersion at a District Hospital in Sierra Leone, What Declining It Would Have Cost the Hospital, and Where the Benefits Went

The Arrangement

From 2018 to 2025, a U.S. school of nursing, called the school here, ran a two-week clinical immersion each year at the District K hospital. Between 10 and 14 students and two faculty members traveled each January. The school donated supplies, paid a fee to the hospital for hosting, and arranged for students to observe and assist in the maternity ward and outpatient clinic under the supervision of local midwives and nurses. Faculty collected survey data on student learning and, in two years, conducted interviews with hospital staff for a study on cross-cultural clinical teaching. The hospital management signed a letter of agreement each year.

This analysis asks whether that agreement represented willing consent, and what the arrangement made possible regardless of the good intentions of the people in it.

The Positions Each Party Occupied

The school needed the hospital more than the hospital's signature suggested. Immersion programs are a recruiting point for nursing schools, and the course carried credit that students had paid for. Without a host, the course would not run.

The hospital needed the school in a different way. The hosting fee covered about two months of the hospital's fuel budget, and the donated supplies included gloves, sutures and delivery kits that were often out of stock. The hospital's management also understood that the school's faculty had contacts with funders who had supported earlier district programs.

Students and faculty occupied a third position. They held the most mobility of anyone in the arrangement: they could leave at the end of two weeks, and their careers did not depend on the hospital's opinion of them. Hospital staff, by contrast, would still be working on the ward in February, and they had every reason to keep relations smooth with visitors who might return with supplies and contacts the following year.

Pricing the Refusal

The test this analysis applies is what declining would have cost the hospital. A cheap refusal would mean the yearly yes was a real choice. An expensive one would mean the yes was arranged by circumstance.

Declining would have cost the hospital the fee, the supplies and a relationship with a source of future support. It would have cost nothing in clinical capacity, because the students did not add skilled labor; supervision took local midwives' time away from patients during the two weeks. In money and supplies, refusal was expensive. In staff time, acceptance was the costly option. The hospital bore a real cost in both directions, and the balance pushed toward yes for reasons unrelated to whether the immersion served its patients.

There is no record that the hospital ever declined a component of the arrangement. That absence does not prove coercion, but where refusal was never exercised and was costly to exercise, agreement proves little.

Following the Benefits

Learning. Students reported growth in cultural awareness and clinical confidence, and the school published these results in program reports. That benefit left with the students.

Data and authorship. The two years of staff interviews became a conference presentation and a manuscript. Hospital staff were interviewed but were not offered authorship, and the hospital did not receive a summary of findings in a form it could use. Guidance on short-term global health activities calls for mutual benefit, host partner input into goals and sharing of results (Lasker et al., 2018; Melby et al., 2016).

Photographs. Students took photographs on the ward that later appeared in the school's recruitment materials. Consent for those images was obtained in English, on forms drafted by the school.

Credentials. Faculty listed the immersion in promotion files. The program also counted toward the school's global health certificate, which it advertised.

Supplies. The donated supplies stayed in the hospital. This is the one benefit that remained where the care happened.

Paternalism as a Specific Act

In January 2022, faculty decided, without consulting the hospital's matron, that students would not be placed in the maternity ward for the first three days because of concern about student distress after a maternal death the previous week. The decision protected students. It also removed planned assistance from a ward that had arranged its staffing around it. The act was taken on the hospital's behalf, by named faculty, on a date, without asking. That is what paternalism looks like inside a case.

Whose Committee Approved It

The interview study was approved by the school's institutional review board in the United States. No review was sought from a Sierra Leone ethics committee. Approval in one country is not approval in the other, and the absence of local review means that hospital staff had no local body to which they could raise concerns about their participation. Critiques of global health practice note that power and decision making in such partnerships tend to sit with institutions in high-income countries (Abimbola & Pai, 2020).

Judging Then by the Standards of Then

It would be unfair to judge a 2018 program by guidance published years later. That is not the situation here. Principles calling for host partner input into goals, mutual benefit and sharing of results were published by 2016 and 2018, during the life of the arrangement (Lasker et al., 2018; Melby et al., 2016). Codes for nongovernmental organizations warning against parallel structures and one-sided benefit date from 2008 (Pfeiffer et al., 2008). The school's own research office required consent and data protection for its U.S. participants. The standards the arrangement fell short of existed and were known to faculty at the time, which is why the judgment can rest on them.

Judgment

The people involved were committed, worked long hours on the ward and acted in good faith throughout. The arrangement, however, placed the hospital in a position where refusal was costly, routed most of the benefits away from the hospital and allowed decisions about its ward and its staff's words to be made elsewhere. The yearly letter of agreement does not establish willing consent under those conditions. The judgment of this analysis is that the arrangement was ethically weak in design, regardless of the quality of the individuals who carried it out, and that the weakness lay in the terms, not the people.

References

Abimbola, S., & Pai, M. (2020). Will global health survive its decolonisation? The Lancet, 396(10263), 1627-1628. https://doi.org/10.1016/S0140-6736(20)32417-X

Lasker, J. N., Aldrink, M., Balasubramaniam, R., Caldron, P., Compton, B., Evert, J., Loh, L. C., Prasad, S., & Siegel, S. (2018). Guidelines for responsible short-term global health activities: Developing common principles. Globalization and Health, 14(1), Article 18. https://doi.org/10.1186/s12992-018-0330-4

Melby, M. K., Loh, L. C., Evert, J., Prater, C., Lin, H., & Khan, O. A. (2016). Beyond medical "missions" to impact-driven short-term experiences in global health (STEGHs): Ethical principles to optimize community benefit and learner experience. Academic Medicine, 91(5), 633-638. https://doi.org/10.1097/ACM.0000000000001009

Pfeiffer, J., Johnson, W., Fort, M., Shakow, A., Hagopian, A., Gloyd, S., & Gimbel-Sherr, K. (2008). Strengthening health systems in poor countries: A code of conduct for nongovernmental organizations. American Journal of Public Health, 98(12), 2134-2140. https://doi.org/10.2105/AJPH.2007.125989