I have finished my book manuscript.
to read about it go to:
I have finished my book manuscript.
to read about it go to:
It seems like I only got home to Hawaii yesterday, but will be leaving for Kathmandu tomorrow. In truth, there are seven months before summer 2014 break. In the past I start planning in November or thereabouts.
There is nothing that says the 2014 trip will be the exact repeat of the 2013 trip. The whole idea is to evolve the training so that it is “owned” by Nepali nurses and docs, and to rely less and less on myself and other videshis.
what are we capable of doing?
first step is to look at organizational capacity. here is what I am thinking:
it’s time to take steps to support and promote Nepali nurses who can teach the content.
it’s time to reach an even wider group of nurses.
time to develop doctors, probably from among the recent crop of MBBS grads now working at Nepal hospitals, to include docs as well as nurses.
still not ready to offer an American-style “official” ACLS course, but steps can be taken to make it closer and closer when we finally do. for now, finding a cost-efficient way to deliver the training is an over-riding factor. Also, delivering a course that serves the needs of Nepal, as opposed to certifying a small number of persons whose goal is to go overseas.
second step is to actually say what I propose:
1) develop a one-day course, and at the end of the day the participant gets an “official card” similar to the ACLS card used in USA. Not a certificate. just as official though.
2) train nurses and doctors who would teach the lecture component using the model of mega-code and practical focus.
3) organize and conduct even more sessions than we did in 2013. we did sixteen 3-day sessions and trained 534 persons. thirty in each cohort.
why not still keep thirty in each cohort and offer fifty sessions? or seventy? In USA this training is offered widely and “owned” by everyone. Why not in Nepal? if we did a one-day course, five days a week, we could reach 2,100 people. wow!
4) devote time to gather equipment that helps the simulation aspect. for example, an actual defibrillator (or more than one) at each session, more mannikins, etc (should we/can we get one location to serve as the sole permanent host site in Kathmandu?)
5) develop a network of resource persons from throughout the country, with even more focus on cities in the Terai, who can also teach this.
6) explore the idea of partnering with some sort of NGO or existing professional group for this purpose. Maybe form our own!
7) make better use of Nepali-language multimedia to promote ACLS in Nepal.
the trick is to find a logical next step which builds on what we did but which does not over-reach into the impossible.
What do you think?
Meera Nosek is a professor of nursing from the University of San Francisco, California USA. She teaches in the USF School of Nursing and in the MPH program there. She will be visiting Kathmandu soon, from Oct 26th 2013 to November 2nd. She has done previous work in global health nursing and she wishes to meet with professional colleagues while in Kathmandu. She contacted me to ask my advice. It is not often that a person with those kinds of credentials will visit KTM. I told her I would send word.
Professor Nosek has a doctoral degree from the University of California at San Francisco; a Master’s degree in Public Health from the University of California at Berkeley; and is a Certified Nurse Midwife. Her usual teaching focus at USF is in the area of nursing research. She is a member of Sigma Theta Tau, the international honor society for nursing scholarship. She is interested to learn more about the maternal-child health delivery system of Nepal.
a request to nurses of Nepal
My advice to her was to meet with nursing faculty, some of the larger teaching hospitals, and the Midwifery Association. If you are reading this, would you please contact her and help make it happen?
What she would like to do
Dr. Nosek has travelled to other countries but this is her first trip to Nepal. She will be learning about the culture and meeting the people. She hopes to develop contacts within the Nepali Nursing Community for future collaboration. USF has a number of ongoing international nursing projects in other parts of the world.
She is a particular resource on the subject of nursing research. She is interested to talk with graduate students and nursing faculty while in Nepal. I told her I would promote her visit, and my hope is that she will be invited to speak to groups of students, tour some of the hospitals, and get a feel for Nepal.
How to contact her
She does not yet have a FaceBook profile or page. When she gets one I will post the link on the FB page for CCNEPal. In the meantime, her email is firstname.lastname@example.org or email@example.com and she will be delighted to hear from nurses in Kathmandu.
A friend of mine in Nepal is doing a BN nursing project on burn care in that country. For me, burn care is an indelible memory of bedside nursing on my trips there. I wrote about it in my first book and it will be part of my second book. For my money, it is the most difficult specialty there is.
I was searching for something else entirely when I came upon an interesting link. It was an article in Jenonline (emergency nursing journal) about a nursing project from the University of Alberta.
here is the link in all it’s glory. The authors describe their teaching approach in improving burn care at Kathmandu Model Hospital (or at least, I think that’s where the host site was…)
I was not previously aware of ReSurge International, which provides reconstructive surgery after burn injury. They are based in California. They have a schedule of teaching in Nepal.
here is a YouTube Video that describes what they do.
Blog editor’s note: Ms. Gaynor Sheahan is a nurse from Australia who has spent time working and teaching in Nepal. She wrote this paper as a graduate school assignment for Monash University. There are people within Nepal writing about nursing education but very few of such essays make it to the wider circulation of international nursing community. I requested that she send this for posting since it addresses a knowledge gap.
Gaynor Sheahan Bio
Presently in Melbourne, Australia. working as Clinical Nurse Specialist in critical care areas, with inservice education portfolio Post Grad student on Master of Nursing Course (due to complete end of 2013) Post Grad Certificate in Emergency Nursing Intensive Care Nursing, Entry into Specialised Practice Accident and Emergency Nursing Certificate. Certificate in workplace training and assessment.
Ms. Sheahan Lived in Nepal for seven years, and worked as volunteer nurse educator at Patan Hospital. Introduced the first system of triage in Nepal at Patan Hospital Emergency Department in 1998. In 2009 and 2011, she taught a two-week “Introduction to Critical Care Nursing Course” at Tansen Mission Hospital, Palpa district. Her email address is firstname.lastname@example.org
Nursing education in Australia could be considered to have undergone a revolution in recent decades with the transfer to tertiary level institutions, and the development of nursing theory and research leading to evidence based nursing practice (Russell, 2000). The move away from didactic teaching to innovative teaching methods such as developing critical thinking, problem based learning, peer-to-peer education, interprofessional learning, student led learning, reflective journals, and use of interactive media are the subject of numerous research studies assessing the impact on improved learning outcomes and clinical experience. Continuing education, professional development, and competency requirements for qualified nurses are also areas where change is taking place (Cowan, Norman, & Coopamah, 2005; Jarvis, 1997). These changes reflect the increasing complexity of nursing and the demand for highly professional nurses. For less developed countries however the development of nurse education has been slower and more difficult. The reasons are complex but poverty, and its associated impact on health, education and development must be included in any consideration. Conflicts, war and displacement of people groups are important additional factors.
Nepal is perhaps more famous for being home to the world’s highest peak, Everest, and for trekking, than it is for its poverty and associated poor health outcomes. Nepal has also been in the news internationally for other reasons: the massacre of its royal family in 2001, and for the decade long civil war with a Maoist insurgency, which has only recently settled into a fragile peace in 2006. Nepal has a relatively young national health system, having been closed to the outside world until 1950 when the first steps were taken
towards a health care system (Gubhaju, 1991; Maxwell & Sinha, 2004). In contrast many countries in the developed world have had some form of universal healthcare and associated nursing education for centuries (Nelson, 1997). In this essay the history of nurse education in Nepal, and the current problems affecting further development of nurse education will be discussed.
One of the poorest and least developed countries in the world, Nepal is a country of nearly 28 million people. Landlocked and bordered by two much bigger and richer neighbours, China and India, Nepal has no railways and few roads. Those roads that do exist are poorly maintained. The poor road infrastructure and the mountainous geography isolate the rural areas and are significant contributory factors to the difficulties in delivering, and seeking, health care (Gubhaju, 1991). 55% live below the international poverty line (Unicef, 2010b). The poor living in rural areas are particularly at risk from the many health problems besetting Nepal: epidemics of infectious disease; natural disasters such as floods, landslides and earthquakes; and malnutrition. Rural populations have also borne the worst effects of the civil war with a conservative estimate of 12,000 Nepalese having been killed between 1996 and 2006, and tens of thousands displaced (World Health Organization, 2007). The decade long civil war formally ended in November 2006. In 2008 the country voted in a Constituent Assembly, with inclusion of Maoist leaders for the first time in a coalition government (World Bank, 2010).
Before 1950, Nepal was isolated from the outside world, with no public health programs and few hospitals. There were fewer than a dozen Nepali doctors and no Nepali nurses (Gubhaju, 1991). The average life expectancy in 1950 was 26 years (Hagan, 1961, as cited by Maxwell & Sinha, 2004). Two Nepali nurse candidates were sent to India to train in 1952, and there were a few Indian trained Nepali midwives (Shahi, 2005). There were no universities and medical education did not exist within the country (K. Regmi, Regmi, & Shahi, 2009). Most health care was provided by family members, with faith healing the most dominant medical system, provided by healers known as ‘jhankri’. The Ayurvedic system of medicine, in existence for centuries, was practiced throughout Nepal (Gubhaju, 1991; Maxwell & Sinha, 2004). Even as recently as 1983 there were 113 Government supported Ayurvedic dispensaries in the country. Tibetan medicine and homeopathy practitioners were also consulted, although they were less prevalent than jhankri (Streefland, 1985).
The first professional nursing school was established in 1956 in Kathmandu, with 15 students for a 3-year hospital based training, resulting in a Certificate of Nursing (Shahi, 2005; Thakur, 1999). In 1959 a second nursing school, the Shanta Bhawan School of Nursing was established, run by a Non-Government Organization, The United Mission to Nepal. Between 1956 and 1971 313 nurses were trained. In 1972 the Institute of Medicine, (IOM) Tribhuvan University, took control of nurse education in Nepal with the New Education System Plan. Nursing in Nepal was still very much focused on hospital based health care, at Proficiency Certificate Level (PCL) (Maxwell & Sinha, 2004; Shahi, 2005; Thakur, 1999). In 1976 Post-basic nursing education was introduced by the IOM. Initially this was developed as a Diploma of Nursing course but became the foundation of the Batchelor of Nursing (BN) program (Maxwell & Sinha, 2004; Thakur, 1999).
A major review of nursing education took place in 1987 and the concept of primary health care (PHC) was introduced into the curriculum, reflecting global trends for delivery of health care in developing countries. PHC was a major step forward in matching the health care needs of the population, which was mainly rural based, with the kind of nurses graduating from nursing schools, with less emphasis on hospital based curative treatment. Nurses began to train rural health workers and traditional birth attendants, and students were sent to work in remote areas for community experience. This new curriculum also attempted to improve nursing practice with the use of nursing research, and to develop the leadership skills of nurses. The IOM established the first Master of Nursing (MN) course in 1995, with a first intake of 4 students (Bentley, 1995; K. Regmi, et al., 2009; Thakur, 1999).
The development of nurse education has been slow however. During the 1980’s and ‘90’s many nursing faculty were recruited soon after graduation and had little clinical experience. What experience they did have, was mainly hospital based which was out of step with the new emphasis on PHC (Ogilvie, 1998; Thakur, 1999). The Nepal Nursing Council (NNC) was established in 1996, responsible for reviewing the nursing curriculum and examination system, nurses’ code of conduct, to maintain a register of nurses, and with responsibility for accreditation of teaching institutions. The NNC also investigates complaints made against nurses (Maxwell & Sinha, 2004; Nepal Nursing Council, 2011) .
By 1999 there were eight nursing campuses in Nepal and approximately 3,000 professional nurses for a population of similar size to Australia. Although there was a need for 160 nurse educators to achieve the stated teacher-nurse ratios set by NNC at the time, the number of teachers actually available was 115. Other issues of concern in 1999 were: the ratio of nurse to patient, especially in rural areas; the number, qualification, and experience of the teaching faculty; and the preference of qualified nurses to work in private rather than government facilities (Thakur, 1999).
The nursing courses offered in Nepal today are based on a two tier system: a Certificate of Nursing, a 3 year training program requiring education to the 10th grade (approximately 16 years of age); and tertiary level courses. The Post Basic Program in Nursing (BN), conducted over 2 years, requires previous completion of the Certificate in Nursing and at least 3 years experience. The most recent program in nursing, the Batchelor of Nursing Science (BSc), started in 2005 with 20 students. The BSc is a direct entry course on satisfactory completion of the School Leaving Certificate at the end of 12th grade (approximately 18 years of age), conducted over 4 years (World Health Organization, 2010). Currently there are 16,171 nurses registered, plus 17,072 auxiliary nurse midwives and 675 foreign nurses (total 33918) (Nepal Nursing Council, 2011). Most registered nurses are PCL trained (Maxwell & Sinha, 2004)
In “Global standards for the initial education of professional nurses and midwives” the World Health Organization states that the future of nursing and midwifery education will depend on the quality of education at the degree level. Research has shown that “a more highly educated nursing workforce not only improves patient safety and quality of care but saves lives” (2009, p.10). A future goal according to WHO, and Maxwell and Sinha (2004) referring to Nepal, would be to encourage continuing education and professional development in accordance with worldwide education trends. Although there is a shortfall in nursing faculty in many countries, nursing schools must produce graduates who demonstrate “critical and analytical thinking” (World Health Organization, 2009, p. 21).
Accurate data as to the current state of Nepal’s nurse education system is difficult to find. What is available is limited, with little research on nurse education in Nepal published in international peer reviewed academic journals. This is perhaps a reflection of the long civil war and its aftermath, continuing political instability, and Nepal’s struggle to overcome its poor economic state in a world experiencing a global financial crisis. The main challenges facing nurse education in Nepal today, according to research and journal articles that are available, will be discussed below, summarized as: lack of experienced nursing educators, lack of critical thinking, gender and cultural issues, a lack of resources, heavy reliance on certificate level nursing staff, a need to further develop nursing education at tertiary level institutions, and a lack of adequate supervision and standardization of private education providers and the nursing courses they provide.
Joe Niemczura, a nurse educator from the University of Hawaii, interviewed Radha Bangdel, the Campus Chief of Lalitpur Nursing Campus (LNC) in Kathmandu, Nepal, in July 2011. Lalitpur Nursing Campus is respected as one of the oldest nursing schools in Nepal, having originated from the Shanta Bhawan nursing school (Maxwell & Sinha, 2004). Bangdel studied for her Master of Education in Thailand. She describes the challenges of nurse education in Nepal today as she sees them: for LNC alone, of 32 nursing faculty positions only 27 are filled and there is a significant lack of resources and multimedia equipment. A videoed tour of the “demonstration” rooms within LNC confirm the need for more up to date equipment, manikins and teaching resources (Niemczura, 2011a, 2011b).
Nepali nurses have often experienced only a rote learning, didactic, teacher led educational system prior to entering nursing school (K. Regmi, 2008). The quality of education in Nepal is generally poor, with high repetition and dropout rates. “Only just over 50% of teachers are trained, they rely on simplistic teacher-centered classroom practices” (Unicef, 2010a, p. 1). Nepali nurses generally follow set routines and procedures with a task orientated focus and do not tend to question treatment decisions or the medical management of patients. Critical thinking is not encouraged, and problem-solving skills are not well developed. Nurses do not generally see being a patient advocate as part of their role. The strict hierarchy with particular respect shown to nurse educators and doctors mean that it can be seen as disrespectful to question a teacher. To admit to not having understood something is tantamount to saying that the teacher has failed to teach you properly (Wetzig, 2004). The traditional educational system from which nurses have come may be at least partly responsible for this highly prescribed functional nursing model and for a lack of skills such as critical thinking.
Gender and cultural issues have been, and continue to be, significant issues in nurse education in Nepal (Maxwell & Sinha, 2004). Nepal is a deeply patriarchal society (Maxwell & Sinha, 2004; R. R. Regmi, 1999). 27% of males in Nepal between the ages of 15 – 19 think that husbands are justified in hitting or beating their wives in certain circumstances. 24% of females in the same age group agree (Unicef, 2010b). Before 1987 only women were admitted to nursing courses. Between 1987 and 1992 men were admitted but Nepali cultural norms were such that it was thought that one male student “can dominate an entire class” and that men were “less caring” than female nurses (Ogilvie, 1998, p. 75). Other concerns were that men might see themselves more as doctors than nurses and be reluctant to provide physical care to patients. However, some nursing faculty suggested that men were effective in community health situations and that more men as nurses would improve the status of nurses in Nepal. During this time there were no male faculty and none were students on the bachelor of nursing courses. In 1992 it was decided to stop admitting men to nursing courses (Maxwell & Sinha, 2004; Ogilvie, 1998). Nursing is still an exclusively female profession in Nepal today although it may have a higher status than it once did with families going into debt so that a daughter may go to nursing school (Maxwell & Sinha, 2004; Niemczura, 2011b).
The increasing number of institutions offering nurse education in Nepal has led to concerns about the quality of courses provided, such as: a lack of uniformity of programs; a lack of minimum standards; inadequate teaching of basic science and communication skills; and a lack of specialized nursing courses (Shahi, 2005). Shahi also recommends that there should be a minimum entry level of 12th grade education to both BN and BSc nursing programs, and electives offered to provide wider options.
Current international research in nurse education examines the use in developed countries of highly technical equipment and resources, such as simulation laboratories and interactive media, which require computer systems, software and equipment, Internet connections and reliable infrastructure for support. The financial cost is often prohibitive in countries such as Nepal, already heavily dependent on international aid. Only 2% of the population in Nepal has Internet access (Unicef, 2010b). Technical support, maintenance, repairs, and an irregular electricity supply can also be significant problems. Load shedding, where certain areas do not have electricity for parts of the day, is widespread. In the Kathmandu valley the current load shedding is for 2 hours a day (Republica, 2011) but can be as much as 16 hours a day.
Research examining relatively inexpensive ways of improving nursing education in Nepal, such as possible curriculum changes, different teaching strategies, and interprofessional learning (IPE) has been conducted however. Regmi, K., Regmi, S., and Shahi (2009) used interviews and focus group discussions with nursing students and nursing tutors from various educational institutions in Nepal to review the present 3-year undergraduate curriculum and to compare to current curriculum theories/models. Appropriate strategies to improve nursing education in Nepal were also explored. The curriculum was first developed in 1987 and revisions were made in 1987 and 2007, with changes reflecting a move away from a subject-centered focus to student-centered, and to encompass PHC strategies. K. Regmi et al concluded that, although significant progress has been made in nursing education in Nepal, challenges remain and must be addressed in order to improve the quality of nursing education and practice: a lack of appropriate teaching-learning methodologies; the “tutors’ incompetencies” (K. Regmi, et al., 2009, p. 52); poor education policy; the need to further develop student-centered learning and participation, using approaches which focus on problem-based learning; increased clinical experience to narrow the gap between theory and practice; and a greater focus on evidence-based learning. The development of a system to improve the performance of faculty by evaluation of learning outcomes was also suggested. Self directed learning and reflective learning were considered to be important ways student nurses could be introduced to the concept of ongoing professional development (K. Regmi, et al., 2009).
An IPE study, described as a collaborative learning situation where two or more professional groups learn from and about each other, examined the attitudes of 30 final year medical students and 30 third year undergraduate nurses toward IPE through questionnaires and focus groups. Some of the problems identified were: the differences in educational attitudes between medical and nursing students, and a significant gap in
teaching-learning. The authors concluded that the benefits of IPE in this study were: improved communication skills in relation to both colleagues and patients; the development of a team approach towards patient care; and increased understanding of each other’s position in regard to educational and clinical situations (K. R. Regmi & Regmi, 2010). IPE a cost effective way of sharing resources and training, especially in developing countries such as Nepal and ultimately could deliver better health outcomes (K. R. Regmi & Regmi, 2010; Yan, Gilbert, & Hoffman, 2007).
Manisha Nair and Premila Webster (2010) conducted a literature review into published research in the last 10 years on education for health professionals in less developed countries such as India, classified as Emerging Market Economies (EME). Some of the conclusions reached echo many of the problems identified in the above Nepali research: outdated curriculum and teaching methods; the unprecedented growth of private medical and nursing educational institutions, mostly unregulated; the quality of education provided; the shortage of educators; and the need for a standardized accreditation system (Nair & Webster, 2010). It would not be unreasonable to conclude that these problems may be worse in Nepal compared to EME given that Nepal is not yet developed enough to be considered an EME.
In conclusion, health statistics for Nepal remain dire: life expectancy in Nepal is 65 years for men and 69 years for women (Australia: 80 years for men and 84 years for women, one of the highest in the world) The probability of dying before the age of 5 years is 48 per 1,000 live births, with most deaths due to diarrhoea, birth asphyxia and pneumonia (Australia: 5 per 1,000 live births) The total expenditure on health per capita is US$69 (Australia: US$ 3,383). Maternal mortality ratio is 380 per 100,000 live births, one of the worst in the world (global average 260 per 100,000 live births, Australia: 8 per 100,000 live births) (World Health Organization, 2011a, 2011b, 2011c). In a country where 80% of the population lives in rural areas the concentration of the health workforce and health facilities is significantly weighted towards urban areas (Maxwell & Sinha, 2004). Understandably, priority is often given to those programs that will have an immediate impact on health outcomes, such as reducing the maternal mortality rate and deaths of children before the age of five. It could be argued that longer-term health goals, such as improving and regulating nursing education have had to take a lower priority.
However, the development of nursing education in Nepal in less than 60 years can be viewed as remarkable, especially when considered against a backdrop of an impoverished economy, rapid social change, civil war, and political instability. Nepal has progressed since 1950 from a feudal, medieval country closed from the rest of the world to a democratic nation, with a developing health system (Maxwell & Sinha, 2004). Nepal is a country at “a crossroads, an open moment” in its history, the next few years considered to be critical, with long-standing development challenges at a time of global economic crisis (World Bank, 2010, p. 1). There are no easy solutions to the challenges within nursing education today in Nepal, at least some of which depend upon a stronger economy, political stability, an improved, regulated educational system, and significant infrastructure. Encouraging signs with the growth of Nepal specific research and tertiary level education, and the increasing number of nurses undertaking Masters level education allow some optimism that nursing education in Nepal will mirror the changes that have already taken place in developed countries over the last few decades (Maxwell & Sinha, 2004). The most effective immediate changes however may be those that involve the least expense and that could be adopted in Nepal today without waiting for political and economic stability, such as curriculum changes, IPE, and the use of innovative and creative teaching strategies. Cultural factors, such as gender and status in a patriarchal society may however be important in the success of any changes.
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This is not complete or comprehensive but I thought I should get it out there. if you can provide info that helps make it more accurate, please email me.
It’s paradoxical that Nepal should have an oversupply of nurses. the market is hard to explain. I guess it’s more like an undersupply of funding for nursing jobs. It’s competitive and it favors the employer. In my view, there are way too many PCL-level programs, and not enough nurses with B Sc education. I believe strongly that B Sc education should be required for critical care positions.
The way the education system is structured is not conducive to staying in one position for long. For example, a PCL nurse can only get into a BN program if they have two years of work experience; this creates turnover in the staff nurse positions as soon as a nurse gets the two years.
An unofficial survey?
I trained 534 nurses this summer, and met about 300 more in various ways. My whole summer project consisted of outreach to nurses. I bet I know more nurses than you do!
So I have access to a lot of people who can answer questions about nursing. before I left Kathmandu I sat down with some nurse-friends and I asked them about the job market. I was specifically interested in nurse wages because a previous blog entry on that topic gets a lot of hits.
so, they told me the “conventional wisdom” of the nursing job market. You may not be familiar with the term “conventional wisdom” – it means that these are things everybody thinks to be true, and they make sense but nobody has really verified anything and nobody can really pin down the source.
SGNHC - pays about 28,000 nrs per month for a staff nurse. a senior nurse makes more. this is a government hospital (see below)
MMCVTVC - part of TUTH - pays 34,000 per month. “the working hours are long” – and more $$$ allowance comes with shift work etc. these are the most desirable jobs in Kathmandu because of this. in summer 2013, TUTH conducted a hiring exam and 2,000 nurses took it, to compete for 25 slots. They interviewed about 200 candidates. “MMCVTVC has lots of public holidays”
(there was a rumor that my course served inadvertently as a prep course for the exam because the government test was weighted heavily toward cardiac. I do know that quite a few of my 2011 students now work there.)
Norvic Hospital - for staff nurse, average is 10,000 nrs per month
Bir Hospital – 17,000 to 18,000 depends on shift.
Om - 18,000 nrs per month
Patan Hospital – 22,000
being a nursing faculty – 12,000 to 13,000 for beginning faculty, this goes higher if the person has experience.
It’s not a scientific survey.
For example, the nurses told me that Grand Hospital is the up and coming place to work since it is modern and funded by an INGO from Thailand.
some of the hospital will expect you to volunteer for a period of up to six months before you can expect to be offered a paid position as a staff nurse.
Some hospitals work with educational consultancies to offer “training” in critical care. a typical one recently was for a six week period and the nurse was expected to pay 24,000 nrs. I was told that these are considered to be a bad deal by most young nurses, and on the nursing FaceBook pages, you can read negative comments about them. “They don’t really teach you anything, there is no classroom theory, you just work alongside the nurses.” The advantage, though, is to have something on your resume that tells a future foreign employer that you have done critical care in Nepal. “a resume is everything and it better be spotless.”
The role of consultancies in nursing is not to be understated. Any nurse going abroad ends up choosing a consultancy. These are big business. Part of Nepal’s development strategy is to promote foreign work, so as to increase remittances to home. There is a Western Union sign about every hundred meters on some streets. all the Western Union offices are there to handle remittance money.
do you disagree? do you wish to correct something?
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Preliminary report of CCNEPal 2013
The CCNEPal 2013 summer critical care nursing project is winding down. A single one-day training event remains, then we pack up our tents.
This was an extension of the 2011 summer program which trained 190 nurses in critical care skills.
It should be noted that the lead instructor holds a Nepali RN license and is legally able to teach in Nepal in accordance with the laws. This project was conducted on a voluntary basis.
Needs assessment was conducted from 2007 to 2009 while the principal was doing bedside teaching of nursing students at PCL level in Nepal, and through interviews with a wide range of stakeholders familiar with standards of acute care in Nepal.
It became obvious that there is presently a paradigm shift in acute care in Nepal, with the desire to offer more sophisticated services that rely on critical care nurses, as opposed to the longstanding focus on public health-oriented preventative care which accepted a lower level of acute services. This has many implications, not the least of which is the issue of sustainability of the funding model.
A related issue is a change in tobacco use among youth, which will cause an epidemic of heart disease in the next ten to twenty years. Government policies about tobacco are in place but need to be strengthened as well. Tobacco is a ticking time-bomb in Nepal.
Present systems to train nurses in this skillset are not meeting the manpower needs.
Description of program:
We did sixteen 3-day sessions of critical care skills training between May and August 2013. These sessions were based on the American Heart Association (AHA) standards for Advanced Cardiac Life Support (ACLS) modified to meet the needs of Nepali nurses. We did not use PowerPoint or DVD resources due to unreliability of local electricity and technology and the learning style of Nepali students.
The 3-day course also included basic science not generally taught to nurses in Nepal. For a course outline and objectives, click on the link. A FaceBook page and YouTube provides ample photographic and video documentation of events.
Teaching style and classroom management
The CCNEPal project was designed to deliver skill content but as a corollary benefit, the style of classroom management is universally considered to be new to Nepal. Many participants were working as nursing instructors in schools of nursing. For these, the course modeled an active teaching and learning style. Specific further efforts to work with nursing teachers may be a worthwhile related project in the future.
Low tech equipment
Teaching an “Official” ACLS course in Nepal is cost-prohibitive due to detailed requirements for specific expensive equipment. Certain standards of AHA have limited applicability for Nepal (AEDs). We improvised various methods of teaching which used low-tech substitutes. We did bring 2 “A.T. 35″ rhythm simulators (Pinnacle Technologies, Michigan USA) which were extremely worthwhile. These will be in the custody of one of our major partners until we return.
The project distributed donated nursing textbooks at various locations. There were not as many books as in past years.
The project relied on a FaceBook page to market the program, and the main site counted more than 3,200 “likes.”
Some sessions were sponsored by teaching hospitals associated with medical schools in Nepal, some were hosted by schools of nursing, and one was conducted for a consultancy sponsoring an NCLEX prep course. Four of the sessions in Kathmandu were offered at Lalitpur Nursing Campus (LNC) on a “first-come first-serve” enrollment basis. Interest in the course continued to grow as the summer progressed. Hospitals continued to request the training for their location after the schedule was full, based on highly positive word-of-mouth. Likewise, not all nurses could be accommodated.
Several one-day sessions were added as well which did not lead to a certificate.
The 3-day session was offered at 5 locations outside Kathmandu Valley during a 19-day “Road Trip” in June, and a return trip to Pokhara (Nepal’s second-largest city) in August. The Road Trip would not have been possible without the logistical support of the hosts in the out-of-Valley locations, especially since the final schedule was improvised with a short planning frame. At each location the session included an assessment of hospital learning needs with the nursing matron and administrators.
Amanda Giles, RN,BSN
In the early part of the project, a nurse from Canada, Amanda Giles, RN, was involved and also did some training on the hospital wards of various locations. She was excellent but was not able to stay for the duration.
As the summer progressed, we relied on Nepali nurses to help run each session of the program, which was invaluable. With that approach we directly mentored almost two dozen nepali nurses in scenario-based teaching of ACLS mega-code and teamwork skills. These are future leaders. In the long run, every step to promote Nepali “ownership” of teaching must be taken and this is a beginning.
Final exam and certificate
Course completion included a final exam in which a team of nurses performed a practical exam based on ACLS megacode, in front of their peers. A certificate was given to each participant who passed the final exam. The numbers were as follows:
Shahid Gangalal National Heart Center (SGNHC) 31
Secured Life International Group (NCLEX group) (Chaubahil) 25
Sumeru Hospital (Dhapakhel) 18
College of Medical Sciences (CMS) (Bharatpur) 39
Chitwan Medical College (CMC) (Bharatpur) 34
Kaski Sewa (Pokhara) 34
Lumbini Medical College (LMC) (Palpa) 32
Mayadevi Technical College (MTC) Butwal 30
Lalitpur Nursing Campus (LNC) #1 29
Nepal Medical College (NMC) (including 15 MDs) 45
Kist Medical College (KMC) 31
Iwamura Health Science Institute (Bhaktapur) 28
Kaski Sewa (repeat) 64
Final total number of certificates:
519 nurses and 15 MDs.
There were many people whose assistance and support of project goals eased the path of CCNEPal 2013, and it is simply not possible to acknowledge all of them. At times, this project seemed to be riding a wave of good karma in which many conspired to remove obstacles from the path. This is an indicator of the deep desire of Nepali health professionals to offer the best for their fellow citizens and patients, in the highest traditions of medicine and nursing. In a deep sense we were able to make room for joy during the learning process.
Names of specific contact persons:
Matron Mrs. Nita Dongol Shrestha, RN (SGNHC)
Mrs Shirley Evans, RN, BS (SLI group)
Deputy Matron Mrs. Susan Maharjan, RN (Sumeru Hospital)
Matron Mrs Sita Parajuli RN and faculty Mrs Arju Naraula, RN (CMS)
Medical school faculty Moti Chapagain, MD (CMC)
Matron Sushila Neupane, RN (Kaski Sewa Hospital, Pokhara)
Matron Bandana Pokharel, RN (LMC)
Campus Chief Mrs Bedana Thulung, RN (MTC)
shweta shakya, rn
Campus Chief Mrs Radha Bangdel, RN, (LNC)
Campus Chief Mrs. Kalpana Shrestha, RN (NMC)
Matron Mrs. Urmila Shrestha,RN(NMC)
Chief of Anesthesiology Gautam Bajracharya, MD (NMC)
Matron Mrs. Ambhika Ghimire, rn (Kist)
Nursing faculty Ms. Manisha Daubangour, RN ( Iwamura).
Prospective future hosts or participants are encouraged to contact these individuals to gather their perspective as to the project. Of course, the 519 nurses and 15 doctors who enrolled are likely to also have an opinion.
There is more to share regarding how this project interfaces with nursing education in Nepal, as well as the complicated manpower/labor market issues in the country.
The emphasis on large training numbers was partly intended to demonstrate the need among a wide swath of nurses in the hopes of creating public opinion that would favor this area of education.
Time will be taken to reflect on the structure and goals of future efforts before another project is planned. Clearly, a network of people now exists, contacts have been made, and good will has been established.
This report will continue to evolve. Feedback and ideas are welcome. It has been an honor and privilege to work with so many fine people dedicated to the advancement of medical care in Nepal.
Joe Niemczura, RN, MS