Extent, nature and consequences of performing outside scope of training in global health

Abstract

BackgroundGlobalization has made it possible for global health professionals and trainees to participate in short-term training and professional experiences in a variety of clinical- and non-clinical activities across borders. Consequently, greater numbers of healthcare professionals and trainees from high-income countries (HICs) are working or volunteering abroad and participating in short-term experiences in low- and middle-income countries (LMICs). How effective these activities are in advancing global health and in addressing the crisis of human resources for health remains controversial. What is known, however, is that during these short-term experiences in global health (STEGH), health professionals and those in training often face substantive ethical challenges. A common dilemma described is that of acting outside of one’s scope of training. However, the frequency, nature, circumstances, and consequences of performing outside scope of training (POST) have not been well-explored or quantified.MethodsThe authors conducted an online survey of HIC health professionals and trainees working or volunteering in LMICs about their experiences with POST, within the last 5 years.ResultsA total of 223 survey responses were included in the final analysis. Half (49%) of respondents reported having been asked to perform outside their scope of training; of these, 61% reported POST. Trainees were nearly twice as likely as licensed professionals to report POST. Common reasons cited for POST were a mismatch of skills with host expectations, suboptimal supervision at host sites, inadequate preparation to decline POST, a perceived lack of alternative options and emergency situations. Many of the respondents who reported POST expressed moral distress that persisted over time.ConclusionsGiven that POST is ethically problematic and legally impermissible, the high rates of being asked, and deciding to do so, were notable. Based on these findings, the authors suggest that additional efforts are needed to reduce the incidence of POST during STEGH, including pre-departure training to navigate dilemmas concerning POST, clear communication regarding expectations, and greater attention to the moral distress experienced by those contending with POST.

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“…Some reasons for low vaccination coverage include transitory staff [19], busy schedule [20], lack of money to pay for the vaccine [21] and forgetfulness [22]. This is complicated by shortage of skilled HCWs, especially in low income countries, which may compel students to carry out procedures on their own especially in emergency situations [23,24]. Unfortunately, the students are inexperienced and may have inadequate training in universal precautions [25,26].…”

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“…This can result in well-intentioned international treatment programs combining medical trips with medical tourism or teams traveling into remote resource areas without the proper safety provisions. Team may also be providing treatment without appropriate follow-up care, and/or professionals who may be practicing internationally beyond the scope of their specialty in their home country (Crump and Sugarman, 2010; Doobay-Persaud et al, 2019). Ultimately, these potential issues may place patients at high risk.…”

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“…1,2 Often, trainees from high-income countries may be asked to and perform outside of their typical scope of practice during STEGH. 3 Although various pre-departure training programs exist 4 , challenges remain in providing trainees with the tools to navigate the ethics and implications of their clinical work and address affronts to personal scope of practice when applied to STEGH.…”

“…Trainees based in HICs often receive highly specialized training and can develop a scope of clinical practice that is narrower than their peers practicing in resource-limited settings (RLS) typically encountered during STEGH. When HIC trainees rotate in these settings, they often report feeling pressure to perform beyond their scope of practice 3,21,23 or experience di culties managing care with unfamiliar and often fewer resources. 13 Trainees must have tools to deal with these pressures unique to STEGH to ensure safety.…”