CCNEPal report of summer 2019 activities

I am back in USA this week, and next week I resume teaching at a nursing college in Tampa, Florida. The flight from Nepal to USA was uneventful but long. Oh wait – I lost my wallet and one of my bags got lost – but overall it was okay. I would recommend Quatar Airlines to anybody.

I was in Nepal eighty-two days. I taught thirteen sessions of my course, and awarded 317 certificates to nurses and doctors. This was fewer sessions and certificates than past summers where I tended to teach about 24 sessions and got close to 600 certificates each time. I had a number of requests to teach additional sessions that I was not able to fulfill, due to travel requirements or the heat.

CoMS Bharatpur

Most of the sessions were at College of Medical Sciences in Bharatpur. This host agency has an airconditioned classroom which has ample space and they supported conditions that made it easy to feel good about the quality of learning we could provide. My partners there have known me since 2011. They provide fooding and lodging (with aircon!) and they were always upbeat. As in past summers, I note that the students at CoMS are more often from the Terai and indeed to complete their government service in Terai; this is important because Terai needs to work more on outcomes for health than other regions. I think I could walk into any number of subsidiary hospitals in Terai and be greeted by a nurse or doctor who took my course at CoMS. Like all good Universities, CoMS serves as a knowledge node from which expertise billows out.

CoMS was kind enough to allow me to teach a session to nurses and faculty of NPI Hospital and NPI college of nursing. I had previously taught a session at the NPI hospital but in an area that lacked aircon.


Yes. For some reason, the heat in Terai got to me this summer more than in previous visits. We were on the fringe of the same weather system that produced such killing heat in Delhi and Rajasthan for the early part of the summer – 42 degrees C every day. Many people in the region died of heat-related illness.

From In South Asia, there is less night-time cooling than you would expect.

I knew it would be hot, but not this hot. My problem is, I can only go to Nepal in summer due to my teaching job. I was asked to teach in other Terai locations, but declined to do so unless there was air con. Also, my highly- anticipated trip to Nepalgunj was postponed indefinitely due to heat, then flooding.


I taught only one session in Kathmandu, at Bir College of Nursing. The audience was BNS students. These persons are returning for a Bechelor’s Degree. The pathway for them is get their PCL, then work two years and return to school. Most of this group were working in the system of government hospitals, and one of the priorities of the Ministry of health is for the BNS students to focus on critical care skills. So the group was an ideal target audience for me. They were so much fun to work with. I returned there a week later for a daylong session on ecg reading, something I don’t normally do.

Other hosts in Kathmandu

I can legally teach my sessions in Kathmandu because I have an RN license in Nepal. However, there were two other host agencies operated by the government that originally wanted me to teach, then requested me to show a letter from the Ministry of Health to authorize my teaching. This is also a pathway to “legally” teaching, but one which I was told by the Nepal Nursing Council that was not needed by me. So the first plans went nowhere. I am exploring the idea of taking steps to get such authorization from the MoH for next year. There are about thirty hospitals int eh government system trying to upgrade their critical care skills, and I am thinking this might be a good focus.

I returned to Terai for one session, at Bharatpur Hospital. The roster there also included faculty from NPI, and from Balkumari and from Maya Devi College, in addition to the nurse who serves as Regional Burn Coordinator.

My daughter the tourist

The last two weeks of the summer were devoted to tourist activities. My older daughter finally visited me in Nepal and we had fun. She later said how much she loved the people and culture here and that “it was the trip of a lifetime.”

The only festival that take place during monsoon is “Gathamuga” in which the frogs save the world. (more or less). It was so much fun!

The itinerary included three days in Chitwan seeing wildlife and interacting with elephants.

Julie never was in the presence of a loose monkey before this trip.

She also got a kurtha jangrawal at a place in Indra Chowk, and went on a yoga retreat.

The kurtha jangrawal is associated with the Newari cultural group. I think she looks terrific wearing this. Lots of videshis buy a sari or a kurtha, but few have this tailored for themselves.

It was good to stop and smell the incense.

Airway Management Trainer

How could I forget! CCNEPal organized a crowdfunding campaign to donate one of these to CoMS. We made a handover on July 25th.

This training tool will provide education to MBBS students, Interns, Medical Officers, and nurses at CoMS for decades. Because the school sends graduates throughout Terai, it is a resource to improve the technical skills for the entire region.

Time to reflect

I now have six or eight months to think about how CCNEPal can help advance the practice of critical care in Nepal. I will be thinking of ways to move the project forward in future years. I expect to decide about the 2020 trip in March or April, then send out an announcement as to available time slots and sessions in April or May.

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Should Every Nursing College in Nepal build their very own hospital? Of course not!

Swasthya Khabar needs to stop attacking and start helping

So there has been a series of newspaper articles in Swasthya Khabar that investigate issues within the nursing profession of Nepal. These have been written in Nepali language, and I start by admitting my Nepali is poor. I use Google translate to get the idea of what they are saying. I think these articles are prompted by the recent results of the nursing licensure exam in which only about a third of nursing college graduates achieved a passing score. Also, there is a desire to use the press as a way to develop public opinion for a plan that will guide further development of nursing as a worthy profession in Nepal.

Outside a nursing college classroom in Kathmandu. In Asian culture, shoes are removed before entering a room.

Naturally the general public needs to learn about the best way to proceed and that is a noble goal to guide the Nepali press in a democracy. All Nepali families wish to support the success of their younger members, and many young persons see the possession of a nursing degree as a ticket to employment in a Nepali hospital or as a vehicle to go abroad and see the world while sending remittance home. They can do this while serving humanity. There is nothing wrong with these aspirations.

Graffiti from the stairwell of a nursing college in Kathmandu. Nursing students often live in a hostel fro three years while studying. The curriculum is regimented and disciplined. Families often accrue debt to send their daughter to nursing college.

The most recent Shasthya Khabar article is: .

The title is:

नर्सिङ शिक्षामा मनपरी : यी ९३ वटा कलेजका आफ्नै अस्पताल छैनन्

स्वास्थ्य, शिक्षा मन्त्रालय, काउन्सिल, सिटिइभिटी र विश्वविद्यालयकै कर्मचारीको मिलेमतो

This is devoted to a discussion of how many of the nursing colleges in Nepal are associated with a hospital. Oh My God! Ninety three are NOT! Now, the fact is, most major hospitals in Nepal operate their own nursing college in the first place. But there are colleges that would be called “free-standing” if they were located in the USA. In fact, the vast majority of nursing colleges in the USA are “free-standing” and it does not hurt the nursing education offered to students in USA.

The reader is invited to look at the Swasthya Kahbar article. I have written a long comment at the bottom, which I will repeat here, edited to improve formatting:

Here is my specific reply to the article in Swasthya Khabar:

(begin quote) This article has strayed from the real issues in nursing education planning. The direction of the article is to accuse all the 93 nursing colleges of breaking the law and suggesting that these colleges need to be penalized. ( and the list of offenders is included, implying that the leaders lack integrity. Are they trying to shame the colleges or would they do better to find a solution?) That is not the way to proceed.

First, it is simply ridiculous to suggest that any nursing college now open their very own hospital with all that it entails. Will the Campus Chief of each nursing college suddenly become a hospital director, employing Medical Officers and Surgeons and operating an Emergency Room and Operating Theater? That idea in itself is ridiculous – of course not. We already have a situation where any group of doctors that can pool their money to build a “hospital” can do so, without any real planning or oversight by any level of government. Why adopt a policy that requires more building construction without consideration of hospitals that already exist nearby?

“Affiliation Agreements”

In USA, it is the general practice for colleges of nursing to operate independently from owning their own hospital, and this would be okay for Nepal too. Of course, in USA each school is required to have an arrangement with the nearby hospitals to allow their students to go there to learn how to take care of patients. Nepal would do well to adopt that approach. A hospital needs nurses, but staff nurses are expensive because to be paid, so it is typical for many of the hospitals in Nepal to start their own nursing college. The labor of the students substitutes for the paid labor of staff nurses. This is a lesson in “economics 101.” In USA these agreements for students to serve at hospitals not owned by their school are called ” affiliation agreements” and the existence of such an agreement should be the proper subject of investigative journalism, not whether the college owns their own hospital.

A better way to explore the issues in nursing education

If you are searching for ways to inform the public about ways to improve nursing education in Nepal, you might consider other areas of reform, such as rewriting the PCL curriculum; re-assigning the development of the PCL program to the Nursing Council and not CTEVT; establishing a higher level of education as a requirement for entry to nursing college in the first place; reforming the overall education system to support women who wish to study science topics; re-assessing the nurse license exam so as to reflect better measuring techniques, and the like.

As for me, it’s true that I am a videshi, but I write a lot about nursing education in Nepal since twelve years. You are invited to read my blog, . Now, there are areas in which nursing education in Nepal can improve, but this article is simply not helpful in describing what those areas may be. Anybody who wishes to discuss this with me is invited to find my blog and make a comment. (end quote)

Does that make any sense to you?

I do think the concept of affiliation agreements is already part of the system being described, but there seems to be selective choice to focus on some other idea in the current situation, and I think the focus needs to be maintained on the quality of education, not the presence or absence of a shiny new building that lacks a reason to serve the public.

Feel free to comment below.

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Practical Tips for Teaching nursing abroad when the students have some English but not quite fluent

Seen ’em come and seen ’em go

Over the past eleven years I have watched others come to Nepal to try to teach something, and not succeed. Maybe they don’t assess the audience before preparing teaching methods, or maybe they overestimate the English language comprehension, or some other unexpected issue. There is a long list of pitfalls. We assume an expert clinician somehow knows how to teach.

This is not limited to westerners trying to teach. I recently spoke with a Nepali doctor who decided to teach the nursing staff a new skill by assigning all of them to read a certain book in English, after which he would administer a written test. Yes, that might have worked in Medical College, but it’s not the best strategy for nurses.

I am not an English teacher, I don’t teach English per se. I teach content related to cardiac resuscitation and nursing, to classrooms of people who can speak some English. The people in my class sometimes possess excellent English proficiency and sometimes very little at all.  It is not my goal to make them speak English, but the goal is to help them  do better resuscitation using critical care skills.

Having said the above, I do find that my background in teaching ESL students is very handy.  Look at it this way: I


The View from the front of the classroom.

n Nepal I am always teaching an entire class of ESL students. Many of them already speak Nepali, and Hindi, and perhaps a third language such as Newari or Maithili, prior to taking up English.

“You can be excellent at this even if you speak no English”

My own list:

  1. start off by going around the room to determine the English language level of each person present.
  2. speak in English using the grammatical structure of the local language especially if it is an Asian language.
  3. learn a few phrases in the local language and especially learn the top ten body language gestures used by the host culture.
  4. don’t use PowerPoint but do use a Whiteboard
  5. don’t use vocabulary words longer than two syllables
  6. stop and define specialized words
  7. don’t speak more than three sentences at a time
  8. don’t bring a pile of handouts
  9. do have a FaceBook page for the class that helps people learn in advance what will happen in class.
  10. build in class activities for small group discussion about the content in the local language
  11. think of an exercise or game to accompany each little segment of learning.
  12. assign the better speakers to buddy up with those who have less comprehension

I learned a new definition of “scaffolding” while researching this blog entry. Scaffolding definition

List of websites to study

I gave my off-the-top-of-the-head list above, but there is already a lot of material out there. Here is a list of URLs I found useful I thought this one was terrific inasmuch as I already use many of these techniques! My sessions rely heavily on simulation and use of medical equipment like Bag-Valve-Mask devices and cardiac monitors. This was a good review of classsroom teaching for those who do not often stand at the head of the room trying to deliver content. another list of things to consider. This one also talked about “scaffolding” which is a fancy way of saying, allow the person to speak their own language as part of the learning.   Another worthwhile read.

When is the longterm outcome?

For nurses who teach overseas, I think there is some expectation that somehow they will return a wiser, more well-rounded person with deeper understanding of the human condition and a more articulate way of expressing the universal truths of life on earth.  This idea of examining your own assumptions of teaching and learning is a prime vehicle for that realm of self-discovery.

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About the 65% Failure rate on June 2019 Nepal Nurse License exam – some factors to consider

Two-thirds failure rate on June 2019 Nursing License Exam

The recent pass rate for the Nursing License Exam in Nepal was 35% announced in July. In other words, 65% of the examinees failed the exam. The exam is a two-and-a-half-hour paper and pencil test with multiple choice questions in English, and while the scores are not released, the test-take must answer at least 50% of questions correctly. A sample of typical questions on the exam can be found here: These sample questions were published around the time of the 2012 exam. 

The announcement about the exam from the Nepal Nursing Council

There was a reaction in the media, and throughout the country.  Nursing education is expensive in Nepal and many young women enter the field with the idea of possibly working in Australia, the EU, Gulf Countries, or the USA to earn remittance money.  For many years, an upper-caste young woman would have never been allowed to pursue nursing as a career, but this has changed dramatically in the last ten years or so, as it has become recognized that a woman working outside the home in a foreign country can send money back. A parallel trend exists in Medical education here as well. 

PCL education is a challenge

The vast majority of women enroll in Proficiency Level Certificate (PCL) programs, and there are eighty such around the country. You can enroll in PCL even if you don’t pass the SLC exam. The SLC is referred to as “the iron gate” and these days about 20% do not pass. This is better than it used to be. In other words, after passing tenth grade at the age of sixteen a girl can enroll in nursing school here. She could graduate at the age of nineteen

If the nursing exam was constructed by the same people who were in charge of the old SLC exam, that is a problem. The SLC mindset was to disqualify everyone, not to really measure anything. Any good teacher soon learns that it is easy to construct an exam that nobody can pass, not even themselves. 

During the time of the Constituent Assembly, the Nursing Council attempted to institute a system of regulating the establishment of new nursing programs, but they were over-ruled in a dramatic fashion when a different political party came to power. The government took control of new nursing programs and loosened the requirements to start a PCL program. At the time, the Nepal Nursing Council leaders were replaced. There were rumors that money changed hands.

Population Boom a Factor

Now, to be fair, the government had a problem at that time, which was how to provide a career path (other than homemaking or shopkeeping) for young women, since there are so many young persons in Nepal. There has been a “baby boom” and to create the future, jobs must be created. PCL nursing was proposed as one avenue to prepare girls from the village for hospital work. Often, the government advisors did not really have an understanding as to the responsibilities of nurses and the knowledge base required. In about 2013, I recall attending a lunch with an American anthropologist and some women’s advocates who were in favor of relaxing the standards of nursing education mainly to give employment, heedless of any academic requirements. They wanted to create lower levels of health workers that would not be as stringent as nursing education. They failed to see that this was a step backwards, not forwards. 

Previous Problems

The high failure rate of the licensure exam is not a new thing. In 2014, the first year it was implemented, there was an outcry due to the failure rate. At that time, I wrote in my blog that I believed the minimum education prior to admission to nursing school should be “SLC plus two” – meaning that an additional two years of science education should be taken, and thereby increasing the age at which a woman is admitted to nursing school, to eighteen with a resulting higher maturity level. At the time, B SC programs were just coming into existence in Nepal. There has always been a paradox in B Sc nursing education. Nurses trained at the B Sc level are less likely to be subservient to doctors and are trained to speak up on behalf of the patient. At many hospitals, doctors perceived them as a threat and resisted hiring B Sc nurses since they were more likely to advocate for holding the doctors to a higher standard. In those days fewer women attended MBBS programs. B Sc education needs to be covered in a separate blog. 

I have written about nursing and nursing education issues in Nepal since 2011 on this very blog, and you can browse the 270 previous entries to see the general focus of my work. I first came to Nepal in 2007 to teach at Tansen Nursing School ,a PCL program in Palpa district. 

There has not always been a licensing exam for nurses in Nepal. This was started around 2012, partly because the International Council of Nurses pressured the Nepali government to comply with international standards for nursing education so as to promote the portability of a nursing education across national borders. In other words, without adequate credentialling, a nurse who moved to another country from Nepal would be required to take their nursing education all over again from the beginning before becoming eligible for licensure in a new country.  

At the PCL level it is not uncommon for the nursing faculty to only have a PCL degree themselves and be only a few years older than the students. There are fewer role models. This has been changing but not quickly enough. 

Which Language to use for exam?

Now, the language of instruction and the language of the textbooks is an issue. Most textbooks are written in English, and supposedly the language of instruction in nursing is English. The licensure exam is in English. This presents a variety of problems. First, even if the textbooks were in Nepali, Nepali is not the first language of many of the students and it would not be feasible to write editions of each book in, say, Maithili or Bhojpuri. Next, despite the official language of instruction being English, there are commonly accepted ways to work around this, and these exist throughout all levels in the Nepali system of education, form the very beginning. Many schools use the least amount of paper for their students and rely on memorization. 

How people study in a resource-limited environment

In nursing, nobody can afford to buy a personal textbook; libraries are not amply stocked, and the jargon of medicine and nursing is difficult to learn ( this is true even for American nursing students). There is a lot of highly specialized vocabulary. Nobody studies “alone” – they study in groups. In other words, five students get together, the best English-speaker reads it out loud, and they discuss it in Nepali to gain comprehension. In the cities more students own a laptop but this is not the case everywhere.

There is nothing wrong with Nepali language

Use of Nepali bhasa is actually close to what it should be. This is Nepal; the patients speak Nepali; the nurses will work in Nepali language to meet Nepali health needs. But there is tremendous variability of English language proficiency across the country. If you meet a nursing student in Kathmandu who is fluent, do not think that they represent all nursing students everywhere. In my classes that I teach, I start each session with a quick survey of language ability since I lecture in English. 

Need to re-evaluate the exam itself

I looked at the sample question in the link above from 2012, and I would say that these do not reflect what we would call a “nursing focus” in USA. In brief, the questions rely too much on nurse’s vocabulary and not on the actual decisions a nurse would need to make. In USA there are many examples of the type of question that would appear on the licensure exam. Dozens of sites showing sample questions can be found by Google. For that matter, the National Council of State Boards of Nursing in USA publishes their own test map, and it is very very different than the one for Nepal, being “concept based.” My experience constructing exams in USA tells me that none of the questions in the 2012 sample would be acceptable. Also, when a nurse struggles with language, is it reasonable to impose a 180-minute limit on the exam? Are there numbers available as to who was unable to complete the exam in this time?

So, the exam results leave many questions unanswered, starting with the validity of the exam, the way it is delivered, and the way it is used.

Please feel free to share, and to comment below. I invite feedback on this blog, especially if it will improve accuracy. If you wish to give feedback but are reluctant to speak publicly, send an email to me at 

Next Blog?

Also, I will add another blog on the topic of what I think needs to be done. Stay tuned.

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Techniques for any Nurse or Nursing Student who is not a native English speaker.

This will be brief. I wrote a piece on my other blog that describes how to use the settings feature of YouTube to improve your language skills before taking NCLEX, or starting nursing school in USA.

I have found that my tips for Nepali nurses who want to go to USA are read all over the world, not just Nepal. This one is also likely to appeal to a wide audience.

click here:

Feel free to share widely!

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June 22, 2019 Stop and Smell the Incense in Kathmandu

CCNEPal completed session number eleven yesterday with 38 students from the BNS and BMS program at Bir Nursing Campus. This was the third time I have worked with that school and I appreciate the people there. Since the earthquake they are in temporary space at Gaushala, the neighborhood inside the ring road, just south of Pashupattinath temple. Part of our space was a nice verandah but I was cautioned not to leave any equipment lying around loose, because they often get daily visits from members of the Pashupattinath monkey troupe, known for being aggressive. I am trying to picture exactly what a monkey might do with a Bag–Valve-Mask but my mind goes blank. Never make eye contact with a wild monkey.

This brings the total of certificates to 279 nurses and doctors. If I were to continue on this pace I would be in step with a final total of about 600, which has been what I accomplished in each of the last two years.

The campus includes two floors of hostel rooms. About six to a room. Those are mosquito nets hanging from the ceiling. I asked some students to take this for me and they obliged. This is not the same as a “typical dorm room” in USA.

Almost all of the students in the BNS batch seemed to be nurses already working at government hospitals in outlying districts. They plan to return to the outlying districts after completion. This is because they are doing the schooling with loans that will be repaid by service at a government hospital. What this means for me is that Bir Nursing Campus is a fine location for this training. The nurses who took it here will bring their new skills and knowledge of the training approach, to districts in far reaches that I would be unlikely to visit.

At Bir we did the anatomy lab. This is a very short video showing one of the maneuvers we display.

I was told that the group at Bir are given a specific concentration in critical care nursing, the only such one in all of the government system of nursing campuses. I don’t think I understood this until now. That makes me twice as happy to have trained them with my course!

Upcoming schedule

My time in Terai was jampacked with teaching, a choice I made. Ten sessions in five weeks. I am proud of all I accomplished. But now I am back in Kathmandu and I have decided to take a week off and focus on school work for fall semester.

People ask how I manage to get people doing megacode as much I do. My scheme is to divide the usual class of thirty into five groups of five, and designate five others to be my “assistants” for the class. The group helps me choose the “assistants.” I teach mostly in English, but when each assistant gets with a group, they conduct the scenario in Nepali and coach the class members in Nepali. In any given batch, they make it come alive and my course manages to avoid falling into the “one more videshi with a powerpoint and lots of handouts” trap. The engagement is nonstop and energetic. These guys were the assistants at Bir Nursing campus.


Monsoon is due to start any day now, after a few false alarms. I think we could use the rain.

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Crowdfunding an Airway Management Trainer for doctors and nurses in Nepal summer 2019

I am in Bharatpur Nepal teaching critical care skills as before. My partner here is the College of Medical Sciences, a well-established medical college that supplies doctors and nurses who will practice throughout the Terai region. I met with them to discuss the training needs, and the Chief of Anesthesia told me he really wished they had an Airway Management Trainer, because he has many people to train on endotracheal intubation ( putting a breathing tube down the throat of a person). It is not an easy skill to master, and there is a conundrum: how do you learn to do this if you are doing it for the very first time on an actual person?

The answer: You need a simulator! Most medical schools, nursing schools and paramedic programs have these in USA, and the student gets time to go through the micro-techniques as many times as they like with no time pressure, when learning.

This is what an Airway Management Trainer looks like. This one is from the Laerdal company and is considered to be the best.

Okay. These are not cheap, and they are not readily available in Nepal.

I thought about it and decided to start a GoFundMe campaign to help defray the cost of an airway management trainer. Here is the link:

What exactly does it do and how does it help?

Here is a fourteen minute description of the set of skills you can learn using the exact brand of simulator we want to get:

I think after you see the video, and think about it, you can see why this is an important skill to teach using a simulator!

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