Judith A. Paice

Health-Care Structure

Understand the existing health-care structure and what health care is available to all or for select populations. What is the extent of health-care services? Are there clinics for preventive care, or is most care obtained in the hospital? Is home care available with support from nurses and other professionals? Are emergency services available (eg, does the region have ambulances to transport and emergency departments to accept critically ill patients)? Where do patients obtain medications, and do they have to pay out of pocket for these? Do most people die in the hospital or at home? While websites and government sources are valuable, verify this information with clinicians since the clinical reality may be quite different.

Available Medications

To provide useful guidance in symptom management, it is necessary to have a list of available medications used to treat pain, nausea, dyspnea, constipation/diarrhea, wounds, and other symptoms commonly seen in oncology. Your presentation may need to be modified based upon these available drugs (Table 2). Where do patients obtain medications, and do they pay out of pocket for these? There are limitations on availability and access to opioids around the world.^[7] Which opioids are available and actually used? What is the process for obtaining a supply of an opioid for a person with cancer? For example, in some countries, physicians can order only one week's worth of medication at a time. In other countries, patients must obtain opioids from the police station rather than a pharmacy. In several settings, only the patient, not family members, can pick up the medication from the dispensing site. And in a few countries, only parenteral opioids are available. It is also helpful to understand issues such as the prevalence of drug trafficking in the region and how this might affect local drug laws. Are traditional medicines, such as herbal therapies, or other techniques commonly used? It is helpful to be aware of these practices and incorporate them into teaching plans where appropriate.

Education of Health-Care Professionals

International education in palliative care should consider how physicians, nurses, pharmacists, and others are educated. Is the educational system very traditional and formal, with little interaction between students and teachers? Professionals trained in this manner may be less comfortable when faced with role-play, learning through discussion, or other Socratic educational methods. That does not mean that one should exclude these methods when planning the curriculum but, rather, be prepared for silence and possibly even discomfort when first introduced. Seek guidance from local educators as to what methods will be acceptable.

Who is included in the health-care team? Are psychologists available, and are chaplains considered part of health-care services? What is the relationship between physicians, nurses, and other team members? Is collegiality accepted, or is there a hierarchy that limits true teamwork? What is the status of physicians, nurses, and other professionals in the region? In some areas, physicians are highly regarded and financially compensated accordingly. In other parts of the world, physicians have very low social status, respect, and compensation. Within diverse cultures, compensation and acceptance of tips (or bribes) to see a patient or perform an intervention may be accepted practice. Attitudes toward work hours may differ from the Western perspective. In some cultures, socialization and development of personal relationships may be considered more important than other aspects of the workload.^[8]

Planning in advance to know the targeted attendees is helpful. It is advisable to inquire if the hosts might consider inviting representatives from the ministry of health, the appropriate drug institutes, other key government officials, as well as medical, nursing, and pharmacy leaders who can become champions for access to pain relief and palliative care. Having multiple disciplines and leaders from health care and government at the same program can foster ongoing communication and understanding. Include chief educators as they can incorporate this content into their respective curricula.

Plan the Curriculum and the Program

The importance of cultural issues when developing content cannot be overstated.^[9] Factors that might affect pain expression and language or cultural beliefs about death and dying will greatly impact content for teaching. Be aware of local religious and spiritual beliefs impacting pain and palliative care. Consider issues surrounding disclosure of diagnosis and prognosis. Autonomy may not be the prevailing perspective as seen in North America. Ensure that slides are culturally correct and that pictures and illustrations are appropriate. Having the host country leaders review the curriculum in advance is advisable. Avoid cartoons as these may not translate well. Use case examples, but ensure that they represent the types of patients and scenarios seen by the audience. It is also important to avoid being ethnocentric as Western medicine has much to learn from other approaches. It is very helpful to use case studies from the host country. In some settings, trainers will not have access to computers and projectors, limiting the role of PowerPoint slides. Paper presentations or the use of flip-charts may be more accessible.

Consider the need for translation and, if so, which type will be used. Simultaneous interpretation generally requires a sound booth and headphones for participants, and may be more expensive. Consecutive interpretation requires that the instructor present blocks of information, usually a sentence or two, followed by the interpreter providing the content in the appropriate language. This requires speakers to plan much shorter presentations with up to 50% less content being delivered. In either case, trained interpreters can benefit from seeing the slides in advance so they can prepare and clarify prior to the presentation.

When developing an agenda, inquire about the usual times for breaks and meals, as well as time for prayers or other activities. What is considered a “full day” varies around the world, as does the value of adhering rigidly to a schedule. International education generally means that the agenda is fluid; once you are actually in the country and providing the course, other needs may arise. A common mistake is trying to squeeze in too much content. Ask your host to meet prior to the program and, optimally, plan for time before the course to tour health-care facilities. Arrange for a time to meet with key medical, nursing, pharmacy, and governmental leaders who are not scheduled to attend the meeting but might somehow influence curricula and practice. In some settings, local media may be alerted to generate local interest in the topic. Communicate with your host about these opportunities so that arrangements can be made in advance.

For resource-poor countries, consider asking for donations from colleagues before leaving, including books, CDs, and medical supplies. Check local regulations first, particularly if bringing in medications or equipment. If sending books, some countries require high tariff fees to be paid by the receiver when accepting these packages, creating a financial burden for your hosts. Inquire ahead of time if they have to pay to accept these packages. Additionally, in some resource-poor countries, professionals do not have access to personal or work computers and internet café computers often do not have CD drives. Information on jump drives may be more easily accessible.

Finally, visiting educators may want to pack small gifts to give to hosts and others. These should be easily transported and may include items that represent your city or institution. We have also found bringing candy and small toys to be universally appreciated when visiting pediatric settings. A small portable color printer can be used to print photographs of pediatric patients as some of these children have never seen pictures of themselves. You can also print photographs of participants in the training courses.

Personal Considerations

Several months prior to departure, you should contact your traveler's health information resource to identify which vaccinations and what documents are needed to enter the country. To avoid lost time due to illness, ciprofloxacin and antidiarrheal medicines should be obtained before traveling. It is advisable to update your passport. Some countries require you to have sufficient blank pages in your passport to allow entry into their country. An entry fee paid in cash may be required upon arrival. Travelers should consider the political climate of the country and check the U.S. Department of State website (included in Table 1) for alerts or precautions.

Consider appropriate attire when packing. Clothing should reflect respect for the cultural and religious beliefs of the attendees.

During the Experience

It is very useful to meet with interpreters prior to the presentations to clarify any questions. Translation can be quite complicated. For example, a slide that used the term “caring” was interpreted as “romantic love,” and concepts about suffering and death can take on a cultural meaning. Check with interpreters regularly to determine if the speed of delivery is acceptable. Also, translators may have difficulty with this emotional content. In some instances, interpreters have become tearful and required debriefing after palliative care education events. Consider nonverbal communication and personal space. In some cultures, it may not be appropriate to shake hands or to use two hands. Gestures may have very different meanings in other cultures, so avoid these forms of communication. For example, the “OK” sign commonly used in North America, with the tip of the finger touching the tip of the thumb and the other three fingers extended, is considered an obscene gesture in Brazil.

When using teaching strategies other than lecture, respect that some students may not be comfortable at first with nontraditional approaches. Informal teaching strategies that are valued in North America may be viewed as of poor academic quality in other cultures. Debate and discussion, which may make it seem that the student is questioning a teacher's view, may be seen as disrespectful. At times, eliciting personal reflection and experience can engage the audience. For example, when introducing the topic of communication, health-care professionals in the audience can be asked the following questions:

• If you had cancer, would you want to know?

• How about your prognosis?

• Would you want to know that you had a disease that you could die from?

Following these with “What do you tell your patients?” usually engenders excellent discussion.

We have also found that asking participants to do “homework” can be useful, particularly if the students have been quiet or reluctant to communicate during class. Suggested assignments might include listing the five top barriers to cancer pain management in your setting, describing a difficult death or a death that you made better, or related issues. Reticence to speak during class may be due to discomfort with language skills. Some students feel more comfortable sharing ideas in writing, and these assignments have yielded valuable stories that have helped us to understand their experiences and perspectives.

Since the goal of these educational efforts should be sustained, it is helpful to develop a plan for the future with students. Assist them in identifying goals, as well as action items to meet these goals. Allow time for individual meetings between faculty and students to fine-tune these efforts. This ensures that the educational experience will have a greater likelihood of translation into action. To provide practical assistance, if Internet access is available, spend time with small groups to demonstrate literature searches, useful websites, and other information that will foster continuity.

Faculty should meet after each day of training to modify the planned agenda as needed, to optimally meet the needs of the participants. This also provides needed time to debrief about the day's activities and provide support. Particularly when new to international education, the experience may be overwhelming as the status of health-care in developing countries can cause deep personal reflection.

Finally, celebrate. We have found that many students appreciate the opportunity to have some type of closing ceremony to receive certificates and pins, acknowledge their accomplishments, and encourage their future efforts.

Afterward

E-mail, voiceover Internet services, and videoconferencing software have significantly enhanced global communication. Faculty can make themselves available to the trainees after leaving the country using these technologies. Group conversations via e-mail can help solve problems, provide encouragement, and celebrate successes. Connect attendees with international professional organizations to support ongoing educational efforts. It is very useful to identify the leaders or champions and to plan ongoing support to help sustain their commitment. Many countries do not have professional organizations or support networks. These leaders can exist in isolation and suffer great personal sacrifice to lead palliative care efforts in their country.

Conclusion

When educating about pain and palliative care to a worldwide audience, never make assumptions, expect the unexpected, and be flexible. We have found many of these international teaching experiences to be some of the most exhilarating of our professional lives, providing insight to our own practices and creating lasting relationships with colleagues from around the globe. Ultimately, these efforts will improve care for people with cancer.

Acknowledgments

The authors acknowledge the American Association of Colleges of Nursing and the City of Hope for their ongoing support of the End-of-Life Nursing Education Consortium training activities, as well as the Oncology Nursing Society Foundation and the Open Society Institute for their support of international educational efforts. They also thank Marian Grant for her input.

Health-Care Structure

Understand the existing health-care structure and what health care is available to all or for select populations. What is the extent of health-care services? Are there clinics for preventive care, or is most care obtained in the hospital? Is home care available with support from nurses and other professionals? Are emergency services available (eg, does the region have ambulances to transport and emergency departments to accept critically ill patients)? Where do patients obtain medications, and do they have to pay out of pocket for these? Do most people die in the hospital or at home? While websites and government sources are valuable, verify this information with clinicians since the clinical reality may be quite different.

Available Medications

To provide useful guidance in symptom management, it is necessary to have a list of available medications used to treat pain, nausea, dyspnea, constipation/diarrhea, wounds, and other symptoms commonly seen in oncology. Your presentation may need to be modified based upon these available drugs (Table 2). Where do patients obtain medications, and do they pay out of pocket for these? There are limitations on availability and access to opioids around the world.^[7] Which opioids are available and actually used? What is the process for obtaining a supply of an opioid for a person with cancer? For example, in some countries, physicians can order only one week's worth of medication at a time. In other countries, patients must obtain opioids from the police station rather than a pharmacy. In several settings, only the patient, not family members, can pick up the medication from the dispensing site. And in a few countries, only parenteral opioids are available. It is also helpful to understand issues such as the prevalence of drug trafficking in the region and how this might affect local drug laws. Are traditional medicines, such as herbal therapies, or other techniques commonly used? It is helpful to be aware of these practices and incorporate them into teaching plans where appropriate.

Education of Health-Care Professionals

International education in palliative care should consider how physicians, nurses, pharmacists, and others are educated. Is the educational system very traditional and formal, with little interaction between students and teachers? Professionals trained in this manner may be less comfortable when faced with role-play, learning through discussion, or other Socratic educational methods. That does not mean that one should exclude these methods when planning the curriculum but, rather, be prepared for silence and possibly even discomfort when first introduced. Seek guidance from local educators as to what methods will be acceptable.

Who is included in the health-care team? Are psychologists available, and are chaplains considered part of health-care services? What is the relationship between physicians, nurses, and other team members? Is collegiality accepted, or is there a hierarchy that limits true teamwork? What is the status of physicians, nurses, and other professionals in the region? In some areas, physicians are highly regarded and financially compensated accordingly. In other parts of the world, physicians have very low social status, respect, and compensation. Within diverse cultures, compensation and acceptance of tips (or bribes) to see a patient or perform an intervention may be accepted practice. Attitudes toward work hours may differ from the Western perspective. In some cultures, socialization and development of personal relationships may be considered more important than other aspects of the workload.^[8]

Planning in advance to know the targeted attendees is helpful. It is advisable to inquire if the hosts might consider inviting representatives from the ministry of health, the appropriate drug institutes, other key government officials, as well as medical, nursing, and pharmacy leaders who can become champions for access to pain relief and palliative care. Having multiple disciplines and leaders from health care and government at the same program can foster ongoing communication and understanding. Include chief educators as they can incorporate this content into their respective curricula.

Plan the Curriculum and the Program

The importance of cultural issues when developing content cannot be overstated.^[9] Factors that might affect pain expression and language or cultural beliefs about death and dying will greatly impact content for teaching. Be aware of local religious and spiritual beliefs impacting pain and palliative care. Consider issues surrounding disclosure of diagnosis and prognosis. Autonomy may not be the prevailing perspective as seen in North America. Ensure that slides are culturally correct and that pictures and illustrations are appropriate. Having the host country leaders review the curriculum in advance is advisable. Avoid cartoons as these may not translate well. Use case examples, but ensure that they represent the types of patients and scenarios seen by the audience. It is also important to avoid being ethnocentric as Western medicine has much to learn from other approaches. It is very helpful to use case studies from the host country. In some settings, trainers will not have access to computers and projectors, limiting the role of PowerPoint slides. Paper presentations or the use of flip-charts may be more accessible.

Consider the need for translation and, if so, which type will be used. Simultaneous interpretation generally requires a sound booth and headphones for participants, and may be more expensive. Consecutive interpretation requires that the instructor present blocks of information, usually a sentence or two, followed by the interpreter providing the content in the appropriate language. This requires speakers to plan much shorter presentations with up to 50% less content being delivered. In either case, trained interpreters can benefit from seeing the slides in advance so they can prepare and clarify prior to the presentation.

When developing an agenda, inquire about the usual times for breaks and meals, as well as time for prayers or other activities. What is considered a “full day” varies around the world, as does the value of adhering rigidly to a schedule. International education generally means that the agenda is fluid; once you are actually in the country and providing the course, other needs may arise. A common mistake is trying to squeeze in too much content. Ask your host to meet prior to the program and, optimally, plan for time before the course to tour health-care facilities. Arrange for a time to meet with key medical, nursing, pharmacy, and governmental leaders who are not scheduled to attend the meeting but might somehow influence curricula and practice. In some settings, local media may be alerted to generate local interest in the topic. Communicate with your host about these opportunities so that arrangements can be made in advance.

For resource-poor countries, consider asking for donations from colleagues before leaving, including books, CDs, and medical supplies. Check local regulations first, particularly if bringing in medications or equipment. If sending books, some countries require high tariff fees to be paid by the receiver when accepting these packages, creating a financial burden for your hosts. Inquire ahead of time if they have to pay to accept these packages. Additionally, in some resource-poor countries, professionals do not have access to personal or work computers and internet café computers often do not have CD drives. Information on jump drives may be more easily accessible.

Finally, visiting educators may want to pack small gifts to give to hosts and others. These should be easily transported and may include items that represent your city or institution. We have also found bringing candy and small toys to be universally appreciated when visiting pediatric settings. A small portable color printer can be used to print photographs of pediatric patients as some of these children have never seen pictures of themselves. You can also print photographs of participants in the training courses.

Personal Considerations

Several months prior to departure, you should contact your traveler's health information resource to identify which vaccinations and what documents are needed to enter the country. To avoid lost time due to illness, ciprofloxacin and antidiarrheal medicines should be obtained before traveling. It is advisable to update your passport. Some countries require you to have sufficient blank pages in your passport to allow entry into their country. An entry fee paid in cash may be required upon arrival. Travelers should consider the political climate of the country and check the U.S. Department of State website (included in Table 1) for alerts or precautions.

Consider appropriate attire when packing. Clothing should reflect respect for the cultural and religious beliefs of the attendees.

During the Experience

It is very useful to meet with interpreters prior to the presentations to clarify any questions. Translation can be quite complicated. For example, a slide that used the term “caring” was interpreted as “romantic love,” and concepts about suffering and death can take on a cultural meaning. Check with interpreters regularly to determine if the speed of delivery is acceptable. Also, translators may have difficulty with this emotional content. In some instances, interpreters have become tearful and required debriefing after palliative care education events. Consider nonverbal communication and personal space. In some cultures, it may not be appropriate to shake hands or to use two hands. Gestures may have very different meanings in other cultures, so avoid these forms of communication. For example, the “OK” sign commonly used in North America, with the tip of the finger touching the tip of the thumb and the other three fingers extended, is considered an obscene gesture in Brazil.

When using teaching strategies other than lecture, respect that some students may not be comfortable at first with nontraditional approaches. Informal teaching strategies that are valued in North America may be viewed as of poor academic quality in other cultures. Debate and discussion, which may make it seem that the student is questioning a teacher's view, may be seen as disrespectful. At times, eliciting personal reflection and experience can engage the audience. For example, when introducing the topic of communication, health-care professionals in the audience can be asked the following questions:

• If you had cancer, would you want to know?

• How about your prognosis?

• Would you want to know that you had a disease that you could die from?

Following these with “What do you tell your patients?” usually engenders excellent discussion.

We have also found that asking participants to do “homework” can be useful, particularly if the students have been quiet or reluctant to communicate during class. Suggested assignments might include listing the five top barriers to cancer pain management in your setting, describing a difficult death or a death that you made better, or related issues. Reticence to speak during class may be due to discomfort with language skills. Some students feel more comfortable sharing ideas in writing, and these assignments have yielded valuable stories that have helped us to understand their experiences and perspectives.

Since the goal of these educational efforts should be sustained, it is helpful to develop a plan for the future with students. Assist them in identifying goals, as well as action items to meet these goals. Allow time for individual meetings between faculty and students to fine-tune these efforts. This ensures that the educational experience will have a greater likelihood of translation into action. To provide practical assistance, if Internet access is available, spend time with small groups to demonstrate literature searches, useful websites, and other information that will foster continuity.

Faculty should meet after each day of training to modify the planned agenda as needed, to optimally meet the needs of the participants. This also provides needed time to debrief about the day's activities and provide support. Particularly when new to international education, the experience may be overwhelming as the status of health-care in developing countries can cause deep personal reflection.

Finally, celebrate. We have found that many students appreciate the opportunity to have some type of closing ceremony to receive certificates and pins, acknowledge their accomplishments, and encourage their future efforts.

Afterward

E-mail, voiceover Internet services, and videoconferencing software have significantly enhanced global communication. Faculty can make themselves available to the trainees after leaving the country using these technologies. Group conversations via e-mail can help solve problems, provide encouragement, and celebrate successes. Connect attendees with international professional organizations to support ongoing educational efforts. It is very useful to identify the leaders or champions and to plan ongoing support to help sustain their commitment. Many countries do not have professional organizations or support networks. These leaders can exist in isolation and suffer great personal sacrifice to lead palliative care efforts in their country.

Conclusion

When educating about pain and palliative care to a worldwide audience, never make assumptions, expect the unexpected, and be flexible. We have found many of these international teaching experiences to be some of the most exhilarating of our professional lives, providing insight to our own practices and creating lasting relationships with colleagues from around the globe. Ultimately, these efforts will improve care for people with cancer.

Acknowledgments

The authors acknowledge the American Association of Colleges of Nursing and the City of Hope for their ongoing support of the End-of-Life Nursing Education Consortium training activities, as well as the Oncology Nursing Society Foundation and the Open Society Institute for their support of international educational efforts. They also thank Marian Grant for her input.

Health-Care Structure

Understand the existing health-care structure and what health care is available to all or for select populations. What is the extent of health-care services? Are there clinics for preventive care, or is most care obtained in the hospital? Is home care available with support from nurses and other professionals? Are emergency services available (eg, does the region have ambulances to transport and emergency departments to accept critically ill patients)? Where do patients obtain medications, and do they have to pay out of pocket for these? Do most people die in the hospital or at home? While websites and government sources are valuable, verify this information with clinicians since the clinical reality may be quite different.

Available Medications

To provide useful guidance in symptom management, it is necessary to have a list of available medications used to treat pain, nausea, dyspnea, constipation/diarrhea, wounds, and other symptoms commonly seen in oncology. Your presentation may need to be modified based upon these available drugs (Table 2). Where do patients obtain medications, and do they pay out of pocket for these? There are limitations on availability and access to opioids around the world.^[7] Which opioids are available and actually used? What is the process for obtaining a supply of an opioid for a person with cancer? For example, in some countries, physicians can order only one week's worth of medication at a time. In other countries, patients must obtain opioids from the police station rather than a pharmacy. In several settings, only the patient, not family members, can pick up the medication from the dispensing site. And in a few countries, only parenteral opioids are available. It is also helpful to understand issues such as the prevalence of drug trafficking in the region and how this might affect local drug laws. Are traditional medicines, such as herbal therapies, or other techniques commonly used? It is helpful to be aware of these practices and incorporate them into teaching plans where appropriate.

Education of Health-Care Professionals

International education in palliative care should consider how physicians, nurses, pharmacists, and others are educated. Is the educational system very traditional and formal, with little interaction between students and teachers? Professionals trained in this manner may be less comfortable when faced with role-play, learning through discussion, or other Socratic educational methods. That does not mean that one should exclude these methods when planning the curriculum but, rather, be prepared for silence and possibly even discomfort when first introduced. Seek guidance from local educators as to what methods will be acceptable.

Who is included in the health-care team? Are psychologists available, and are chaplains considered part of health-care services? What is the relationship between physicians, nurses, and other team members? Is collegiality accepted, or is there a hierarchy that limits true teamwork? What is the status of physicians, nurses, and other professionals in the region? In some areas, physicians are highly regarded and financially compensated accordingly. In other parts of the world, physicians have very low social status, respect, and compensation. Within diverse cultures, compensation and acceptance of tips (or bribes) to see a patient or perform an intervention may be accepted practice. Attitudes toward work hours may differ from the Western perspective. In some cultures, socialization and development of personal relationships may be considered more important than other aspects of the workload.^[8]

Planning in advance to know the targeted attendees is helpful. It is advisable to inquire if the hosts might consider inviting representatives from the ministry of health, the appropriate drug institutes, other key government officials, as well as medical, nursing, and pharmacy leaders who can become champions for access to pain relief and palliative care. Having multiple disciplines and leaders from health care and government at the same program can foster ongoing communication and understanding. Include chief educators as they can incorporate this content into their respective curricula.

Plan the Curriculum and the Program

The importance of cultural issues when developing content cannot be overstated.^[9] Factors that might affect pain expression and language or cultural beliefs about death and dying will greatly impact content for teaching. Be aware of local religious and spiritual beliefs impacting pain and palliative care. Consider issues surrounding disclosure of diagnosis and prognosis. Autonomy may not be the prevailing perspective as seen in North America. Ensure that slides are culturally correct and that pictures and illustrations are appropriate. Having the host country leaders review the curriculum in advance is advisable. Avoid cartoons as these may not translate well. Use case examples, but ensure that they represent the types of patients and scenarios seen by the audience. It is also important to avoid being ethnocentric as Western medicine has much to learn from other approaches. It is very helpful to use case studies from the host country. In some settings, trainers will not have access to computers and projectors, limiting the role of PowerPoint slides. Paper presentations or the use of flip-charts may be more accessible.

Consider the need for translation and, if so, which type will be used. Simultaneous interpretation generally requires a sound booth and headphones for participants, and may be more expensive. Consecutive interpretation requires that the instructor present blocks of information, usually a sentence or two, followed by the interpreter providing the content in the appropriate language. This requires speakers to plan much shorter presentations with up to 50% less content being delivered. In either case, trained interpreters can benefit from seeing the slides in advance so they can prepare and clarify prior to the presentation.

When developing an agenda, inquire about the usual times for breaks and meals, as well as time for prayers or other activities. What is considered a “full day” varies around the world, as does the value of adhering rigidly to a schedule. International education generally means that the agenda is fluid; once you are actually in the country and providing the course, other needs may arise. A common mistake is trying to squeeze in too much content. Ask your host to meet prior to the program and, optimally, plan for time before the course to tour health-care facilities. Arrange for a time to meet with key medical, nursing, pharmacy, and governmental leaders who are not scheduled to attend the meeting but might somehow influence curricula and practice. In some settings, local media may be alerted to generate local interest in the topic. Communicate with your host about these opportunities so that arrangements can be made in advance.

For resource-poor countries, consider asking for donations from colleagues before leaving, including books, CDs, and medical supplies. Check local regulations first, particularly if bringing in medications or equipment. If sending books, some countries require high tariff fees to be paid by the receiver when accepting these packages, creating a financial burden for your hosts. Inquire ahead of time if they have to pay to accept these packages. Additionally, in some resource-poor countries, professionals do not have access to personal or work computers and internet café computers often do not have CD drives. Information on jump drives may be more easily accessible.

Finally, visiting educators may want to pack small gifts to give to hosts and others. These should be easily transported and may include items that represent your city or institution. We have also found bringing candy and small toys to be universally appreciated when visiting pediatric settings. A small portable color printer can be used to print photographs of pediatric patients as some of these children have never seen pictures of themselves. You can also print photographs of participants in the training courses.

Personal Considerations

Several months prior to departure, you should contact your traveler's health information resource to identify which vaccinations and what documents are needed to enter the country. To avoid lost time due to illness, ciprofloxacin and antidiarrheal medicines should be obtained before traveling. It is advisable to update your passport. Some countries require you to have sufficient blank pages in your passport to allow entry into their country. An entry fee paid in cash may be required upon arrival. Travelers should consider the political climate of the country and check the U.S. Department of State website (included in Table 1) for alerts or precautions.

Consider appropriate attire when packing. Clothing should reflect respect for the cultural and religious beliefs of the attendees.

During the Experience

It is very useful to meet with interpreters prior to the presentations to clarify any questions. Translation can be quite complicated. For example, a slide that used the term “caring” was interpreted as “romantic love,” and concepts about suffering and death can take on a cultural meaning. Check with interpreters regularly to determine if the speed of delivery is acceptable. Also, translators may have difficulty with this emotional content. In some instances, interpreters have become tearful and required debriefing after palliative care education events. Consider nonverbal communication and personal space. In some cultures, it may not be appropriate to shake hands or to use two hands. Gestures may have very different meanings in other cultures, so avoid these forms of communication. For example, the “OK” sign commonly used in North America, with the tip of the finger touching the tip of the thumb and the other three fingers extended, is considered an obscene gesture in Brazil.

When using teaching strategies other than lecture, respect that some students may not be comfortable at first with nontraditional approaches. Informal teaching strategies that are valued in North America may be viewed as of poor academic quality in other cultures. Debate and discussion, which may make it seem that the student is questioning a teacher's view, may be seen as disrespectful. At times, eliciting personal reflection and experience can engage the audience. For example, when introducing the topic of communication, health-care professionals in the audience can be asked the following questions:

• If you had cancer, would you want to know?

• How about your prognosis?

• Would you want to know that you had a disease that you could die from?

Following these with “What do you tell your patients?” usually engenders excellent discussion.

We have also found that asking participants to do “homework” can be useful, particularly if the students have been quiet or reluctant to communicate during class. Suggested assignments might include listing the five top barriers to cancer pain management in your setting, describing a difficult death or a death that you made better, or related issues. Reticence to speak during class may be due to discomfort with language skills. Some students feel more comfortable sharing ideas in writing, and these assignments have yielded valuable stories that have helped us to understand their experiences and perspectives.

Since the goal of these educational efforts should be sustained, it is helpful to develop a plan for the future with students. Assist them in identifying goals, as well as action items to meet these goals. Allow time for individual meetings between faculty and students to fine-tune these efforts. This ensures that the educational experience will have a greater likelihood of translation into action. To provide practical assistance, if Internet access is available, spend time with small groups to demonstrate literature searches, useful websites, and other information that will foster continuity.

Faculty should meet after each day of training to modify the planned agenda as needed, to optimally meet the needs of the participants. This also provides needed time to debrief about the day's activities and provide support. Particularly when new to international education, the experience may be overwhelming as the status of health-care in developing countries can cause deep personal reflection.

Finally, celebrate. We have found that many students appreciate the opportunity to have some type of closing ceremony to receive certificates and pins, acknowledge their accomplishments, and encourage their future efforts.

Afterward

E-mail, voiceover Internet services, and videoconferencing software have significantly enhanced global communication. Faculty can make themselves available to the trainees after leaving the country using these technologies. Group conversations via e-mail can help solve problems, provide encouragement, and celebrate successes. Connect attendees with international professional organizations to support ongoing educational efforts. It is very useful to identify the leaders or champions and to plan ongoing support to help sustain their commitment. Many countries do not have professional organizations or support networks. These leaders can exist in isolation and suffer great personal sacrifice to lead palliative care efforts in their country.

Conclusion

When educating about pain and palliative care to a worldwide audience, never make assumptions, expect the unexpected, and be flexible. We have found many of these international teaching experiences to be some of the most exhilarating of our professional lives, providing insight to our own practices and creating lasting relationships with colleagues from around the globe. Ultimately, these efforts will improve care for people with cancer.

Acknowledgments

The authors acknowledge the American Association of Colleges of Nursing and the City of Hope for their ongoing support of the End-of-Life Nursing Education Consortium training activities, as well as the Oncology Nursing Society Foundation and the Open Society Institute for their support of international educational efforts. They also thank Marian Grant for her input.