By Randall Shirley
Among the five nurses, one is clearly different. She doesn't wear an ishar over her hair like the others, and she doesn't easily join the conversation as it's mostly in Arabic with only smatterings of English. But when one nurse complains about a hurt foot, BYU nursing student Cheryl Gerdy laughingly asks if she'd like a piggy-back ride. "A what?" the Jordanian student nurses query. Cheryl explains the concept of piggy-back, and the injured nurse declines with a smile and a blush.
Soon the group stops at a doorway where a lovely Palestinian woman greets and invites them into the courtyard of her home. Inside the courtyard two women quickly adjust their veils when they see men are present; they then continue to clean and cut eggplant and squash. A wrinkled, elderly Bedouin woman reclines on a mat against a wall. A disheveled, small boy works to steal a piece of his mother's squash, only to be slapped away.
The student nurses sit along a planter box ledge and visit with the Palestinian family about health concerns. One of the Jordanian students starts to discuss prevention of the common cold and tonsillitis, using a chart of the throat for a visual aid.
Cheryl later explains that her group had gone door to door through the camp seeking out families who wanted to improve their medical knowledge and condition. The nurses simply asked if the family, or anyone they knew, could benefit from educational nursing visits. There was no shortage of open doors.
A reflective smile graces Cheryl's face as she points out a doorway on one side of the courtyard. She explains that "Grandma" lives inside. Due to complications from a stroke several years ago, the 80-year-old matriarch had not been out of the house in over four years prior to the nurses' visits. The family simply didn't have the knowledge to properly care for the woman. "As we walked Grandma in a wheelchair through Baq'qa, she just grinned and looked all around," Cheryl recounts. "It was like she was trying to soak it all in at once. We found a shoe store and tried shoes on her feet. As we did so she cried and cried--not out of pain but of joy. Grandma kept praising Allah. We got her an ice cream cone, and I have never seen anyone so happy. She had to finish the ice cream before she returned home, as in their culture ice cream is for children and she didn't want her daughters to see how much she enjoyed it.
"I can't describe the feelings I had," Cheryl notes with marked sincerity. "The experience made me so happy. I hope that our example and medical teachings will help her family understand that she is not breakable, and needs their attention and time out of her bed and out of the house."
Exploring the nursing profession in Jordan has been a profound experience for Cheryl Gerdy, eleven other BYU student nurses, and faculty member Roseanne Schwartz during fall semester, 1995. The students live and study at the University of Jordan. Time spent at dusty Baq'qa camp is part of a course in community nursing. Private hospitals--some magnificently modern, others not--across Amman are the classroom for a nursing management course. And life mixed inescapably with students from across the Middle East provides a unique setting for a special world religions course focusing on Islam.
Traveling from Amman in any direction, one cannot help but see the dramatic topographic similarities to south-central Utah. The magnificent, ancient stone city of Petra, Jordan's premiere tourist sight, is reason enough to visit the region. The saline buoyancy of the Dead Sea, the Roman ruins of Jerash, exotic markets and nearby Israel have all been part of the group's Middle East experience. But the students have had little time for mainline sightseeing. Their memories of Jordan will be primarily of the nation's people, religion, and culture, not its scenery and museums.
At first glance the Hashemite Kingdom of Jordan may seem an unusual place to establish an ongoing, transcultural nursing program. Surprisingly, BYU has strong ties to the Kingdom, including a formal exchange agreement with the University of Jordan (ideally, Jordanian students and faculty will eventually travel to Provo, although the cost is currently prohibitive).
Locating the international nursing program in Jordan also made sense as Sandra Rogers, Dean of the College of Nursing, had spent substantial time there. English is widely spoken in Jordan, so communication is a minor issue, although society the functions in Arabic. So, while there may have been many "right places" for this program, the puzzle pieces fit to reveal Jordan.
Many Jordanians have studied at BYU, and most of them have returned to work in their homeland. These ties have led to connections within the government of Jordan, and the establishment of a cultural/educational facility owned by the LDS Church in Amman-- the only building in the Arab world displaying the Church's name.
BYU Arabic faculty member James Toronto is in charge of the Amman center and has been closely involved with the student nurses. "Jordan is a very good place for the nursing students to be," he notes. "If they are really interested in learning cross-cultural health care issues, this is a great place to come as it's really challenging to adjust and to get inside of the culture.
Living and studying in the Islamic world is very different from life in Western culture, and that realization begins immediately upon arrival in Jordan. Many women follow the age-old custom of veiling at least their hair, and it is not unusual to see women with full veils covering their faces. Public affection between the sexes is unthinkable, and even spoken communication is rare.
Music on taxi radios is filled with harmonies and instruments discordant to the Western ear. Five times each day the blare of call-to-prayer echoes through the streets and alleys of Amman from tinny loudspeakers atop neighborhood mosques.
Mysterious locales are suddenly a short bus ride away--Baghdad, Damascus, Riyadh, Beirut, Kuwait. These are the haunts of CNN reporters, and knowing they are so close by evokes a tinge of disconcert. "There's a historic rivalry between the Islamic world and the Christian West," Toronto notes, "but they're very hospitable and warm. I've always felt welcome and safe in this part of the world. I feel safer in Amman at any time of day or night than I do in American cities, including Salt Lake."
Studying the concepts of community nursing in an international environment is an obvious fit. But the nursing management course was initially seen as a stretch--a challenge that BYU nursing faculty member Myrna Warnick took with a big dose of skepticism.
Myrna traveled to the Middle East solely to teach the management course. "I went to Jordan thinking I would just accommodate the senior students so they could graduate on schedule," she says. "I came away with very different feelings. I think they're going to be the most flexible group of nurses--people who can really solve problems with a breadth we don't often see. I would go again in a minute."
At the senior level, nursing management teaches problem solving, prioritization, and adaptation--skills that are crucial when handling critical health problems of several patients at once. The students also learn about costs of medical services, the impact of cost on quality of care, and how those might relate to a family's concern for the patient.
While nursing management theory in Jordan is taught on the American pattern, the BYU group quickly discovered differences in practice at the University of Jordan's on-campus medical center--differences problematic to the students' required coursework. In order to accomplish the program's goals, Roseanne Schwartz felt the students should be moved to other medical facilities. So she got out the local phone book and within days had placed all 12 students in private hospitals around the city.
Suzanne Flick, an American expatriate and Assistant Director of Nursing at the new and super-modern Arab Centre for Heart and Special Surgeries, had heard through the local grapevine that there were American nursing students in Jordan. Two days later they appeared at her door. Suzanne saw a gold mine of opportunity for her hospital and jumped at the chance to have BYU students doing management projects at Arab Heart.
"Initially, I didn't see a mutual benefit," she recalls, "I thought they would benefit us, but I didn't realize that we could be of benefit to them."
Suzanne was anxious to have role models for her Jordanian staff to watch. Nurses in Jordan are not traditionally valued as highly as their counterparts in America, and it sometimes shows in their work and job satisfaction. Suzanne hoped that having the BYU nurses in her facility would let her staff see how American nurses dress, act, carry themselves, and relate to patients, and how they value their chosen field.
There is no question in Suzanne's voice as she discusses the benefit the students have been. "I guess the biggest advantage is that the Jordanian staff asks me, 'they send Americans here for training?' and I say, 'yes they do!' Suddenly it builds the self-esteem right up in our staff. It does wonders for their egos."
At each hospital the students work in pairs researching and developing in-depth management projects. At Al Kalidi Hospital a team researches staff turnover. At another hospital two students explore how printed job descriptions are understood and utilized by the hospital staff.
Students Jeanette Broderick and Stephanie Shirley are creating a "competency-based orientation" program for Amman Surgical Centre. Their project entails studying the cost of orienting new staff nurses, concluding that each person learns their job at a different speed. They've developed a 40-page competency "check-off" list for staff nurses so that when an individual nurse is properly trained in a procedure he or she can move on. This provides the Director of Nursing with new ability add staff in a quality and cost-effective way.
Gathering pertinent and useful materials for such a project was no simple task. Broderick and Shirley visited a number of other hospitals in Amman to add depth to their study and requested material from the United States.
Maia Stoker saw a need in one hospital for a list of drug side-effects, so she took on a project to list the 20 most common drugs, their proper uses, and side effects. She then had the guide translated into Arabic for use throughout the hospital.
Any remaining doubt in Warnick's mind was erased when she returned to Jordan from other Middle East travels to hear and grade the students' nursing management presentations at the hospitals. "The projects they did are absolutely top-notch," she comments.
"There were significant challenges in their written reports because of the lack of computers and research materials, but the presentations were so strong, and the outcomes were the best I've seen. The product they're leaving with the Jordanians is excellent."
Amman is built on seven hills, and despite being one of the region's fastest growing cities manages to retain some of the charm of bygone eras. The turrets of mosques pop up above most neighborhoods. The smell of fresh pita bread wafts through alleyways, and the array of colorful, fresh, honey-dripped sweets in shop windows is enough to cause a toothache just by looking.
At a small restaurant in Amman, nursing student Suzanne Johnson discusses the her Middle East experience. "To think that we're literally living with the Jordanians in their dorm at their university is really incredible," Suzanne comments over a bowl of hummous. "If you're going to another country, you need to really get in and live as the locals do."
Deep understanding of another culture is the primary reason for traveling 7,000 miles away from Provo. There is, perhaps, no other profession where such understanding is so crucial. In the smallest rural Utah hospital, nurses are likely to work with Hispanics and Native Americans. In America's larger cities, the population includes people from every corner of the globe.
While cultural understanding of Jordanians and Palestinians is not the same as experience with Brazilians and Vietnamese, the principles of flexibility, listening-between-the-words, and patience are universal.
Some may question why the nurses should travel so far when there are diverse populations along the Wasatch Front that could provide a substantial experience. "Unless you immerse yourself as we have done in Jordan, you don't really understand a culture," is Roseanne Schwartz' answer. "Back in Utah students go home at night to their apartments and roommates, back to the comfort zone. But here they have to live with the culture every day. In the dorms they live as the Jordanians do. There is no doubt they now understand what the Jordanians face in life."
"In the States there is a mixture of cultures, so it is important to learn how to adapt our practice to meet the needs of other people," Suzanne Johnson notes. "When you're taking care of a patient, it's important to see where they're coming from, to try to get into their mind and see the situation from their point of view."
BYU student Daneen Petersen plans for a career in community nursing. She recognizes that a major benefit of studying community nursing in Baq'qa camp is the chance to see so many health problems in a concentrated area. "In Baq'qa we go into homes and see hypertension, diabetes, gangrene, and other problems that people don't understand, and we explain the basics."
"This definitely has given me the ability to find creative ways of reaching out in any culture," Daneen notes. "I realize that it's not really kosher in the States to just go knock on people's doors and say, 'excuse me, are there any sick among you?' But it helps me think of ways to find people and to get them into health clinics.
Daneen has spent a good deal of time in Baq'qa's schools. Her cheerful demeanor and memorable health demonstrations (not to mention long, blond hair) have made her a big hit with the Palestinian youngsters.
"Who can tell me why we need to frequently wash our hands?" she asks a class of junior high girls through a translator. Hands shoot eagerly up, belying the reticence the girls' uniforms and veils imply, and their answers show that the students are not entirely ignorant of the importance of hand-washing.
Daneen uses simple drawings to illustrate times when it is especially important to wash your hands. Then comes the clincher. She brings out a petri dish containing a "dirty hand" bacteria culture, and another with a "clean hand" culture. Daneen explains the disease the germs can cause as she walks around the classroom displaying the sealed dishes. From the looks on the students' faces and their quiet but busy chatter, there is no doubt they will wash their hands more often, and will undoubtedly share this information with their families.
The BYU students have lived in three-person dorm rooms, with two Americans and one Arab student per room. And while they say living with the locals is about the same as any other roommate, opportunities to build cross-cultural bridges abound. It's the perfect laboratory for learning about the Islamic beliefs and customs for the World Religions course taught by James Toronto.
Katie Harkness explains how the situation unfolded when she interviewed Mona, a close Jordanian friend, for a class assignment. "Mona talked about what would happen to non-Muslims and how they would not make it to Paradise. She looked me in the eye, and there was that moment where we knew there was a problem because we are such close friends. In a way she was telling me I'm going to Hell. We cried for a moment, and all I could say is I know God will make our differences equal someday, and she gave me the traditional saying of i'nch Allah, or 'God willing.'"
Learning realities of a religion that the Western media often paints unfairly dark is a dose of real-world culture shock for the BYU group. Toronto has seen deep insights develop through the religion course experience.
"The students have really gotten below the surface," he explains. It's been hard in a lot of ways, but that's what education is all about--stretching yourself, taking yourself out of your comfort zone, examining your beliefs and looking at the experience of other people and what it can do for you."
Arab culture, even in relatively liberal Jordan, inevitably appears to Western eyes as subversive toward women. The sexist realities hit home for the BYU group, as all 12 of the students are women.
The students laugh about going to a movie theater in Amman and being required to sit at the back, despite being the only patrons in the cinema. Arab men tend to think Western women have loose morals, and the students have been stared at, flirted with, and even proposed to. After several months to think about it, wearing veils and sitting in the women's section begins to make some sense to the students.
The BYU students' visibility as Americans, however, has made a real impact on everyone with whom they come into contact. American educated Dr. Raghda Shukri serves as Dean of the Faculty (College) of Nursing at the University of Jordan.
"When I first heard we were having 12 American students I was worried, to tell you the truth," Dean Shukri recalls. "But from our first meeting I noticed that they were very polite. I realized they would know how to handle themselves. I believe these students have changed people's impressions of the United States for good."
The mark made by these 12 has been felt across the campus ("everybody sees them out jogging," Dean Shukri laughs), at hospitals around Amman, among their Jordanian classmates, and within the Palestinian homes at Baq'qa camp.
The BYU students' presence has also built the esteem and image of the nursing program at the University of Jordan. Even though they did not attend the same classes as their Jordanian counterparts, interaction in small groups at Baq'qa camp has created a unique understanding between the American and Arab students. And through the BYU group's efforts at private hospitals, previously closed doors have been opened to students from the University of Jordan.
"They've caused us to think," Dean Shukri explains. "We definitely want them to come back. They created a fresh situation--not only for our college, but for the whole University."
Suzanne Flick at Arab Heart echoes those feelings. "I hope they come back. Students generally are a lot of work to have around, but these BYU nurses are not work at all. To get students like the BYU group is a big, big deal."
The program has functioned remarkably well for the first time out. Benefits have been felt in every aspect, and challenges have been met with substantial success. Most importantly, the BYU students have learned priceless lessons in transcultural nursing. Although the language barrier has occasionally been a hindrance, learning to work with such limitations does have benefits. As one student pointed out, when a nurse works with the victim of a severe stroke, there may be no traditional communication at all, let alone in English.
There is no question that the program has been more than worthwhile to Katie Harkness. "I'm taking a love for international nursing home with me," she states, "and a love for different people, too. At Utah hospitals I'd be taking care of a lot of people just like myself."
Daneen Petersen agrees: "The most beneficial thing for me is having a knowledge of people who are different. I've now seen this culture and learned how to become friends with the Jordanian people. I've been able to get inside their circle and gain a trust with them."
As a new day dawns over the Middle East, several BYU student nurses board a bus bound for Baq'qa. Today one of them might teach a Palestinian family how to avoid household injuries. Other students will hail taxicabs and fan out across Amman. One student's positive attitude might help a struggling Jordanian nurse realize the importance of the nursing profession. Another may share a recently-learned management technique, helping a nursing unit trim costs.
All 12 of them will finish the day better prospective nurses. They will bring home insights into the healing profession and an understanding of human nature that cannot be learned at home. And in this shrinking world, healing and understanding are among the most valuable of assets.
Freelance writer and BYU alumnus Randall Shirley visited the BYU nursing students in Jordan during November, 1995. He lives in Salt Lake City, Utah.