January 5th Update for summer 2019 teaching schedule of CCNEPal

CCNEPal offers a threeday course in critical care skills to nurses of Nepal since 2011. Browse past blog entries on this site to learn about our activities.

As of January 2019, the plan is to arrive in Nepal around May 11th. We will spend time running around Kathmandu for a few days then head to the Terai.

From about May 16th to June 30th we will in Bharatpur, Chitwan “The Medical City of Terai.” We will be based at College of Medical Sciences (“CoMS” also known as “Purano”) in their dedicated classroom and offer about 16 sessions. (yes, sixteen). This is the best classroom we have ever had in Terai.

New Registration Option for Outside Participants

In the past, when CCNEPal has been hosted by a large organization we limited the seats to just the persons from the host organization. This meant we did not always have a consistent class size, and the managers strained to accommodate all the requests from staff while still running the wards. CoMS is eager to solidify their status in providing continuing medical education for the region. In summer 2019 we will reserve five seats per session ( possibly more) for nurses or doctors not affiliated with CoMS. This will allow people from District Hospital, NP Hospital, Cancer Hospital or CMC to send a few nurses or doctors at a time to enroll, for example. It becomes easier to continue to staff the units when a few people at a time go off for training. CCNEPal is excited to have this arrangement. To reserve those seats will require a small cash deposit at the time of registration. We have not yet worked out the specifics as to who to contact to register. We will not accept phone-only registrations or email-only registrations.

We expect to teach other sections of our course in July, possibly as many as six. On a recent blog entry, we described the requirements to host us.

Feel Free to Pas this Along

Locations and dates of additional sessions To Be Announced. Send an email to joeniemczura@gmail.com https://www.facebook.com/2013KtmCriticalCareNursingCourse/

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Ten Rules for the “Flipped Classroom”

Ten Rules for the Flipped Classroom in Nursing School

By Joe Niemczura, RN, MS

Without lot of introduction, this is a tool to help students get into the mindset needed to thrive in a flipped classroom. These are not “rules” – More like guidelines. Except for #8.

Come prepared. Do the reading and homework in advance and watch the videos.

Prepare to interact, part one. Passivity is the enemy to the type of learning we strive for in class. When you do the home work, interact with the material to develop questions on the areas you need to understand.

Prepare to interact, part two. Bring your questions to class and engage in dialog. Study with a group.

Think about “meta-cognition.” You are training your brain to think like a nurse. This involves a system of logic. You can speed this along by thinking about how you think. Put it on the table.

Talk with more than just the teacher. You can learn a lot from the person next to you.

Stay to the end. If you have already mastered the material, you have an obligation to help your peers. Leaving the dialog is a selfish act.

Stay engaged. “Being present” is more than just being present. Put the smartphone down and nobody will get hurt. Exhibit attending behavior at all times.

Respect those around you. Incivility has no place in this classroom.  Examples of incivil behavior can be found in Pearson Volume II page 2650. 

Find a way to use nursing therapeutic communication in all that you do. Every peer; the faculty; the patients; hospital personnel; your own family.

Develop a personal “centering practice” and cultivate it. Remember the “First Rule of Knowledge” from the Buddha.

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Plan now for course with CCNEPal in summer 2019

Destination – the future!

Now that Christmas is over, it will fade out of sight in the rearview mirror as we hit the gas for our destination – 2019. Naturally it starts out as a year full of promise.

Destination – picking up the USA team.

Every good road trip benefits from companions. As in the past, I am willing to bring others with me to experience Acute Care Global Nursing. I am particularly interested to find people to teach PALS and pediatric critical care. The ability to “Code Switch” or learn how, is essential. If this is you, contact me.

Destination –  Kathmandu!

CCNEPal will return to Nepal in summer 2019 for about ten weeks, beginning in mid-May – the day after my teaching job here in Florida wraps up the spring semester. I will fly into Kathmandu of course, spend a day or two organizing things, then head off to the Terai.

Destination – Widespread Clinical Competence!

The main question for me is how to maximize the teaching of the course I do so as to reach the widest possible audience. Last year I had the pleasure to re-connect with persons who I taught five or more years ago and I was flattered when they relayed how important that course had been for them, in terms of building confidence and competence in emergency situations. At this point, I have trained about 4,000 nurses and doctors. It’s true that many joined Nepal’s medical “brain drain” – I bet that 300 are now using those skills in Australia. But most are still in Nepal and there has been progress in shifting the mindset.

Since I first started going there specifically to teach critical care skills, there have been many positive developments. The Nepal Society of Critical Care Medicine has gained prominence and taught more short courses – The one titled BASIC has become more accepted. The Critical Care Nurses Association of Nepal was formed and they have helped develop critical care preceptorship models that are now being adopted more widely.  The Center for Medical Simulation came into being and they run a fully-certified American Heart Association International Training Center, along with having all the manikins and simulators we take for granted in USA. Many nursing faculty from schools around the country of Nepal have taken the course and they too, will bring new confidence passing the skills to their students. During the 2015 earthquakes, hundreds of nurses and doctors trained by me were able to use their skills to save lives. Also as a direct outcome of my training, many Emergency Rooms and Critical Care Units are now equipped with the communication skills and de-escalation techniques that mitigate the threat of “thrashing.”

Destination – the Terai!

As in the past, most of my efforts are centered in the Terai as opposed to Kathmandu. When I left Nepal in 2018, I was talking with my main partners in Terai about ways to use one of the medical colleges as a more well-defined home base so that nurses and doctors in the region could come there.  I need to see if this is still on the agenda. If we can collaborate effectively,  we will be able to schedule twelve or fifteen sessions of the course right from the git-go and each one will have the maximum number of enrollees.

To arrange a session of training with CCNEPal in 2019

I will still have availability to go to other regions to teach. A few years back I wrote the terms under which I will deliver a session. Here they are, again.

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How to host a training session with CCNEPal summer 2019

Contact me by sending email to  joeniemczura@gmail.com

I will travel to locations outside Kathmandu if the host can do the following:

  1. provide a class space suitable for the program. This  needs to be a big space. We move around a lot during this class. It needs: 1) a whiteboard (I do not use PowerPoint) 2) thirty chairs, 3) five patient beds or trolleys for the role play scenarios. 4) air con if possible. The classroom needs to be away from a patient care area. ( we make a lot of noise).img_20160710_144458_panorama_edit
  2. provide a roster of thirty nurses and/or doctors or MBBS students for each session of two, or three days. Nurses take a 3-day sessions and MBBS take the 2-day/ Each participant must attend all sessions of the same class to get the certificate (in other words, the three day class is a three day class – not three one-day classes). arrange for morning chiya and lunch, if there is not a cafeteria.
  3. The sessions are for PCL nurses, B SC nurses, or MBBS. I do not register ANMs in the class. It’s okay if the person is a recent graduate, but the persons need to be working in acute care or intending to work there.
  4. while at a place outside of KTM Valley, the host provides fooding and lodging. I live simply, it can be at a guest house, no need for finest hotel in town. I eat  DBT etc so I’m okay with local food. At some locations, they lodge me in a private room on cabin ward. ( they do not need to check my vital signs though!)
  5. My preferred schedule is to teach six days per week, either two three-day sessions (for nurses) or three two-day sessions (for doctors). I travel on Saturday and repeat. In summer 2016 I stayed two weeks in Pokhara, two in Bharatpur, two in Janakpur, and three in Biratnagar before returning to Kathmandu.
  6. I try to make a “circuit” of sessions, not go out-and-back from Kathmandu all the time. It’s more efficient.
  7. I supply the certificates. I keep a minimum amount of photocopy but we need about six pages per person.
  8. My Nepali is poor ( I am ashamed to admit). Strange as it may seem, that is not an insurmountable obstacle if there are some English speakers. I adapt my teaching techniques so as to “Code Switch” in a certain way. If a person has no English, this may not be the class for them.

Destination – home again!

I have loved the past trips to teach in Nepal, but I also love my present teaching job.  At the end of the summer, the jalopy pulls into the driveway, we shake the dust out of our clothes, and resume our “normal” lives.

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How I am spending the 2018 winter break.

Time for a deep breath

This blog goes a bit dormant when I am back in USA. I returned to my teaching job at an Associate Degree nursing program in Tampa Florida where I carried an ambitious schedule. I was still commuting from Tampa to the Plant City campus, where I taught one section each of the three main courses of the first semester.  Here in Tampa I spent the first six Saturdays helping out in the skills lab of our evening/weekend group. I brought two clinical groups to one of the largest most diversified medical centers in the state.

wednesday group at LRMC orintation

One of my Fall 2018 clinical groups. I think I have had more than a hundred clinical groups in the years  I have been teaching.

I was busy.

Ivory Tower

Over Christmas break I am finally able to be back in Ivory Tower mode. Til now, every time I have had a break I go to Nepal, or to the Pine Tree State (Maine) where one of my daughters is fixing up a house with my son-in-law. I was there last Christmas during a cold and dark time, in a partially-heated building, living like somebody “North of the Wall” in Game of Thrones.

march 14 snow

View out the glass doors in Maine, December 2017. I was working on my daughter’s house for a couple of weeks. One night about a foot of snow came down. We needed to shovel a path to the barbecue.

This time I decided not to go anywhere, and to simply catch up on things.

For spring semester I will still teach the classroom and skills lab of the groups in Plant City, but cut back to just one clinical group which will be here in Tampa. For three days a week, my commuting time will now be much shorter. This ought to simplify my life. Click here for a short video of me inspecting my student’s work at clinical.


Our program uses a computer-based course software system as all colleges do nowadays. Ours is “Canvas.” When it is realizing its potential, Canvas is an amazing online guide, with a grade book, discussion boards, a syllabus, a set of calendars one for  each course, and a smartphone app that allows everyone to view assignments and get reminders to keep on track. The problem with Canvas is that it is only as good as the content that is uploaded to it. In the past semesters I usually returned to Tampa just a short time before the upcoming first day of classes, then threw it together in a general way. I uploaded the bare bones  of the courses I taught, and I added more as the weeks of the semester ticked by.  When you teach the same course for consecutive semesters, you can export the previous  content to the new course. In this way my Canvas pages accumulated a volume of content that kept the students mostly happy.

canvas computer calendar

This is the calendar interface for one month Spring Semester 2019. All the ingredients are right there on the list. There are likely to be some students for which the sight will provoke an anxiety attack. We will help them get over it and mobilize their study time.

I began to prepare for Spring 2019 by importing my content,  giving myself a nice starting point. After all, the bones of the course are dictated by the overall curriculum and I already know what we will discuss in Week 11 for example. What is new is that I am taking ample time to enhance the content in such a way as to provide the clearest possible directions to the students for them to meet all our target outcomes.

Mea Culpa, Mea Culpa, Mea Maxima Culpa

Last semester we changed from the second edition of our main text to the third, but I did not revise all the reading assignments according to the new pagination. We adopted a new companion workbook but I only assigned things from it for part of the time. These days I am going through lists of reading assignments and double-checking to eliminate or minimize the inaccuracy. Looking at the textbooks myself to make sure I can refer the students to various places they need to go. Maximizing workbook assignments and pro-actively thinking of ways to do in-class exercises to support each one. Also, finding relevant videos to accompany the class sessions.

The Teacher’s “Craft”

This type of planning is what we call the craft of educational design from a classroom management viewpoint. It seems simple an elegant for the student but when you take it apart it has depth that may not be immediately apparent. I am not a fan of detailed work like this but it was overdue. When  I assign the students to go to page 2494 and find exemplar 36A,  they will find the page number matches the location.  I have a library of PowerPoints to accompany the course, and a supply of activities we can do in class as group work.

It will be grand!

Video, Narrated PowerPoint, etc

YouTube is still somewhat new, but it seems as though many people have uploaded bits and pieces of video that amplify or clarify areas of content that we all share. These days there is so much video available, that if I go through the trouble to find it and evaluate it ( “curate it” in the lingo of today’s youth) I can string it together so that there is a reference lecture on video to accompany just about every section.  When I add each  link  I am careful to include the length of the video. When the students access the smartphone app, they will be able to call up a number of pre-recorded files, so they can listen while driving, or also watch the videos anywhere they may go, to fit whatever time is available.  The on-line component is so strong that it is approaching the level of an online course. With any luck the classroom portion will take it up a notch.

Guest Faculty

Renowned Faculty with Guest Lecturers from Australia, Kerala India, New York City, and California. I may be the lead teacher in the three courses, but now the virtual course faculty includes about fifty other experts on various other topics, delivering well-researched  material with often excellent graphics. It frees up our face-to-face meeting time so we can discuss the material and apply it, instead of transmitting facts and things to memorize.

Do you need an example? this clicking on this video of  nurse doing a head-to-toe assessment.  We spend weeks teaching the components of this and I always end up modeling how to do it. There needs to be a system but it requires the nurse or nursing student to be interactive. In the video, the nurse hits all the major points. Not only that, but the same people re-did the video with a voice-over play-by-play worthy of Major League Baseball. Sharing this with the students will point the way for them. And yes, this shows a big part of what hospital nurses do all day.

Bicycle etc

I am also taking time to relax, just enjoying my flat. I decided to splurge and get myself some presents –  a book I wanted, a small white elephant, a spice rack for the kitchen – that sort of thing. It’s the nice weather season in Florida and I am also trying to ride each day.  In about ten days we start the Spring semester. I will be ready!

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Team of Quebec Nurse educators to visit Nepal in spring 2019 – want to meet them?

I got a unusual email that led to a phone call.

Hello Joe,

I’m a Canadian nurse and educator, planning a trip to Nepal in the spring.  I have been to Nepal twice before (about 30 years ago) with my husband, we loved the culture and country very much.  In 2012 and 2014 I volunteered (the second time with a 4 person teaching team) in Bangladesh at the Grameen Caledonian College of Nursing.  We offered some workshops to teachers in their nursing program on moving patients safely, CPR, team teaching, skills (venipuncture, etc) and while there we had an opportunity to visit local hospitals and clinics.  Our visit to Nepal would be for about 2 – 3 weeks.
We’ve applied for a small grant to help us come to Nepal to have a similar visit. We’ve been in touch through Nepali friends with the Nursing Dept at Tribhuvan University.  We would also like to connect with a school that offers the ANM program.
In Bangladesh we were able to donate some supplies and equipment through our own fundraising (venipucture arm, cpr mannequins, sliding sheets, etc). We would be prepared to do so in Nepal.
I’ve read your articles before and just thought I’d get in touch to see what suggestions you might have.
Thank you,  Debbi Templeton
This made me smile
How could I ignore such an email? I sometimes get these, and it’s always nice to chat, so I gave her my phone number. We had a delightful conversation. Debbi and her colleagues are just the sort of person who can contribute to nursing education in Nepal.
Ms. Templeton has her BSN from McGill University in Montreal and a MSN from the University of British Columbia. McGill is probably the top nursing program in the country of Canada.
She would be joined by three other nursing educators from the Chateauguay Valley Career Education Centre, located in a rural suburb of Montreal, not far from the border with Vermont, USA. (oh, and her husband, who is not a nurse).
Here is a photo showing the group wearing their kurta in B’desh:

team templeton

Debbi, Kim, Bev, and Daniele

and they toured a tea plantation:

Templeton team (2)

How we can make this work:


First, for them to get travel funding from the Canadian Government, they need a Nepal host school that would provide them a letter of invitation. As I understand it, such a letter is legally accepted by the Nepal government to allow them to teach nursing while in Nepal.

Previous international travel

This group has volunteered in South Asia in the past, as well as central America. This is not their first trip overseas.

Pokhara? Bharatpur?

Next, they will happily collaborate with Nepali nurse educators while in Nepal. They will start in Kathmandu but they are intrigued by the idea of getting out of Kathmandu Valley.

Contact them:

Debbi Templeton is on FaceBook, send her a friend request and get the dialog going!

Her email address is:


This kind of exchange is really wonderful when it works. For me, my blog, the CCNEPal FaceBook page, and the YouTube channel are set up to help westerners prepare for such kind of travel.

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Summary of Summer 2018 CCNEPal activities

This is “late” seeing as how I returned to USA six weeks ago. My job in USA – my “real job” keeps me busy.

Locations and hosts

CCNEPal taught 19 sessions in Nepal in summer 2018, and distributed 593 certificates for our flagship 2-day or 3-day course in Critical Care skills.

CCNEPal taught at:

the National Trauma Center (two sessions),

National Burn Center (two sessions), and

Mediciti Hospital (four sessions).

Then two sessions in Janakpur, following up on the visit of two years ago.

After that, four weeks in Bharatpur. CCNEPal taught College of Medical Sciences interns and nurses, also Narayani Samudayik Hospital and the Zonal Hospital.

Back in Kathmandu, the last session of the summer was at CIWEC Clinic.

Special Guest Colleague

I always put out an announcement for other USA critical care nurses who wish to learn about Nepal health care. This summer, Valerie Aikman, RN, BS,  joined me for the ten weeks.  While I was teaching she was making hospital rounds and applying her experience as a critical care manager alongside the managers of the host institution.  I think people really appreciated her expertise in improving the clinical environment for critical care.

Summer 2019

I plan to seek out other nursing educators for summer 2019 as well. We are always asked to provide specific education on pediatric emergencies but I don’t feel like I personally am qualified to teach this; I don’t have the kind of i-depth knowledge of PALS that I do for ACLS.

At some point I will post a more detailed description of what the experience involves.




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#WarAgainstDoctors in Nepal with #mulukiAeen #WeAreWithYouNMA


The doctors of Nepal are leading a nationwide protest by shutting down hospital services except for emergency cases, starting today ( well, strictly speaking, yesterday since they are a day ahead of us on the International Date Line). The government revised the criminal code to establish a criminal penalty for the doctor when a patient dies under their care. The Nepal Medical Association called for this to be suspended until it can be replaced, but the government did not respond to a two-week deadline.

“All Doctors Will Be In jail Due to New Criminal Code”

Writing in Setopati ( A Nepal online publication), Dr Chakra Raj Pandey wrote:

Our attention has been drawn to some provisions related to doctors and health practitioners in the new General Criminal Code that came into effect from first Bhadra, 2075 (August 17, 2018).

Clause 230 (1) and (2) is full of flaws. It seems that people who do not know anything about medical science have proposed the clause. In fact, it can take many individuals lives. There is nothing small or big in medicine. One tablet can cause anaphylaxis or one surgical incision can cut nerve or artery or even cause septicemia.

Medical error has been defined as an unintended act or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. Heart ailments cause 611 thousand, cancer 585 thousand and medical errors 251 thousand deaths, according to statistics from US Hospitals for 2013.

Looking at clause 230 (3) and (4), any of us can be in prison from three years to whole life.

Hippocratic Oath prohibits all of us from treating any patient with wrong intention. If we do so, we are not physicians. In that situation, our license has to be confiscated by the council or other regulatory bodies. …..

Clause 231 (2) a and b treat malicious treatment by physicians like murders. They state that no physician will treat maliciously, and the physician’s license will be confiscated if there is any concern and complaint about malicious treatment. I have never heard and read about any physician treating maliciously in my life. How can a patient go to a physician who is treating maliciously?

Clause 232 talks about medical negligence. Is it medical error or is it a different thing? If we talk about medical error as medical negligence, there will be no space left in the country’s prisons and there will be no doctors left in the hospitals.

He continues:

So, this law has been put forward without enough homework and no stakeholder was invited in the discussion process. It is still not too late to correct it. I am sure with the able leadership of Prime Minister KP Sharma Oli, this problem can be corrected once and for all.

The discussion, in my view, has to be focused on how to produce able doctors, how to provide life-long education, how to participate in maintenance of certification, how to do clinical and basic science research, how to make better hospitals where doctors can perform best surgeries, treat patients in the best possible way, and how to build safe institution.

It seems our focus has deviated from the main goal. Let physicians and allied specialties come together to show the correct path and solidarity.

Background to the issue

The problem is, Nepal is a Low Income Country with tremendous geographical challenges and an underfunded health system. There are many “excess deaths” in all regions of the country, an “excess death” being defined as one which might not have happened if the best possible medical care had been applied.  A number of these inadvertent bad outcomes garner nationwide publicity. Most notably, for example, if a woman dies in childbirth it is not unusual for the relatives to assault the doctor, vandalize the hospital and demand compensation.   The link will take the reader to a partial list of well-publicized incidents maintained by CCNEPal.

Deja Vu, All Over Again

In September 2017, the NMA strongly protested a similar proposal, one that would have also criminalized the practice of medicine. The government ministers have not gotten the message it seems. At that time an editorial in SwasthyaKabar wrote:

Doctors all over Nepal are now hesitant to take any risks by managing complicated cases on their own, thus leading to many unnecessary referrals to higher centers. This is what they call “defensive medicine.”  Many hospitals are not managing serious cases because of the fear of repercussions if anything goes wrong. They are putting their safety first and being defensive, especially in those areas where they are practicing in small groups without much supervision and guidance. This will lead to a significant increase in the number of cases burdening the public health care system, thereby further decreasing quality and increasing the cost of clinical care. Patients will be directly affected if this continues. The patients from the most vulnerable and marginalized population will be the ones most dramatically affected, given that they do not have any alternative, and cannot afford to pay high out of pocket expenditures to go to private clinics. Health care will not be equitable and affordable to all, by any means.


Root Cause analysis

The custom in Nepal is to simply blame the doctor. In USA we would “drill down” to examine the safety systems in place to pro-actively identify hazards, but nobody seems to have applied this to Nepal before adopting the new law. For example, determining if the hospital owned the right emergency equipment and whether it was in good repair, or perhaps whether the staff was properly trained. Questions such as whether the patient intentionally delayed going to the hospital or did not enroll in prenatal care.  One international NGO that runs a hospital in Nepal did publish one of their own such analyses recently, and it illustrates the points I  am making.

Transfusions as an illustration

Nepal does not have a consistent blood banking system, but does have a population of citizens with AB+ blood, a situation that becomes dire when the person who needs it is a postpartum woman in hemorrhage. (Not the only problem with Nepal’s system for transfusion.) The way the new law is written,  any doctor unable to obtain AB+ blood for such  a patient can go to jail. If this is allowed to let stand, who in their right mind will risk agreeing to deliver the baby of any woman at risk?

Thrashing of doctors and vandalizing hospitals

This is already an issue in Nepal, and in fact it is a problem in all  South Asia, as has been documented in this very blog you are now reading. Regardless of the circumstances of death, it is a widely known cultural practice to blame the doctor and attempt harm. In the recent past, India and other countries have considered a #JailWithoutBail penalty for any patient party that reacts to bad medical news with violence, modeed after a newla in Queensland, Australia. This new law in Nepal achieves the opposite effect, and increases the likelihood that doctors will get thrashed and the perpetrators will be immune from prosecution.

doctors protest Oct 7th 2017

A prior protest by doctors in India to raise awareness of the risk of being thrashed by angry relatives of a patient. The risk of thrashing has nothing to do with the quality of care being delivered.

There is no central registry of inadvertent deaths

The government has no data of which I am aware, which is why I started the tally of cases that received newspaper coverage. There are many equally serious cases that do not receive coverage because they lack the sensational element.  In my travels around Nepal teaching critical care skills to doctors and nurses, I listen to many anecdotal stories of systems failures.

Government Hospitals

It is crystal clear that any doctor working in an underfunded hospital can easily become a scapegoat.  The biggest most underfunded hospitals in Nepal are the District Hospitals and Regional Hospitals. Even more so in rural areas.  Why would any young doctor take the risk and work in a rural government hospital?

Protest in Kathmandu

Here in Nepali language is a video of a protest march.

These are not the kind of people you ordinarily expect to be out marching.

Other background info

More information as to other new and controversial clauses in the newly revised law are listed here.


This preset proposal needs to be withdrawn and all stakeholders need to have input.


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