Editor’s note: Joe Niemczura, RN, MS teaches nursing at the University of Hawaii in Honolulu. He has also taught nursing in a rural area of the Himalayan country of Nepal. Joe was the keynote speaker at NSNA’s 2010 mid-year convention. He was interviewed for this article in IMPRINT in December 2010.
Why did you go to Nepal ?
Like many nurses, I always had a fantasy of volunteering my nursing skills in a Low Income Country. Over the past few years, the television news has shown us images of nurses responding altruistically to events such as Hurricane Katrina, the earthquake in Haiti, the country’s cholera epidemic, or serving with the Red Cross and US military. I had an idealized vision of using my skills to help the poorest people in the world, but I kept being put off for one reason or another. In 2006 I got some travel funding through the University where I teach. Anticipating the ten-week summer vacation afforded faculty, I spent six months in preparation, and finally got on the plane in May 2007. Nepal has a unique local culture that was appealing to me.
Did you go by yourself? How did you find a group to go with?
I didn’t meet my new colleagues until I got there, but I was not by myself. It’s critical to work with a team. In any given country there are non-governmental organizations (NGOs) that work on health issues. Finding the right NGO is critical. In my case, the NGO sent a person to meet me at the Kathmandu Airport who practically held my hand until I was on the bus to my rural location. It’s easy to find an NGO using a simple websearch. Through my websearch I found United Missions to Nepal (UMN), a Christian aid organization serving there since 1952. Even though I am Catholic, the main focus of my trip was to teach nursing, not to convert anybody. I taught at a nursing school with a hundred and twenty students in a three year program. For me, the daily teaching routine was similar to what I do in USA. There were other foreigners from Australia, USA, Sweden, UK, and South Korea – about twenty all told. In essence, they were a sort of support group. Also, the language of instruction was English. For those who are thinking of actually working or volunteering in any country, language is the single most important thing. Start studying the language of the country you have chosen as soon as you can! Otherwise it’s a barrier. I studied Nepali for six months in Honolulu before I left for Nepal.
What was the hospital like?
The hospital had one hundred sixty beds and served about seven hundred thousand people over a wide area with few paved roads. The hospital staff provided care with the least amount of equipment. For example, using clotheslines to dry the hospital linen, and dripping the IVs by hand instead of using infusion pumps. They also recycled the latex gloves. The illnesses and problems of the patients were a direct reflection of very specific issues of lack of resources, poverty and poor public health infrastructure. For example, all the diarrhea patients could be traced back to the lack of clean water. The typical COPD patient was a woman; this was because it was the woman’s job to cook over a smoky woodstove inside a kitchen all day. We also saw more infectious diseases like Meningitis and TB. There were far more burn injuries, things you would not normally deal with in the USA, including bites from venomous snakes. But there were differences in the way the nurses were trained, as well. The model of care was “functional nursing” – one nurse gave all the meds, another nurse did all the wound dressings. The staffing was limited, and it was difficult to respond if a patient worsened unexpectedly. All in all, the nurses were very resourceful.
You wrote a lot about snake bites in your book.
In South Asia tens of thousands of people die each year from snake bites. Compare that to less than a dozen a year in USA. Snake antivenin only works if you give it before envenomation happens. After that, the person dies by suffocation because of respiratory paralysis. I became locally famous for teaching the hospital staff how to use the mechanical ventilator somebody donated. We ventilated our first victim for three days. At one point we took turns ambu-bagging him for eight hours.
In your keynote address that was a very dramatic story.
I knew it was a lifetime story when the patient walked out of the hospital. In hindsight, I did not expect to be some kind of hero while in Nepal, I simply expected to learn how they did things. I had discarded the idea that anybody would think I was superior in some way simply because I was American. This is critical – you only get the respect you earn. And yet, when they asked me to work on the ventilator problem, it was to fill a real need of theirs. So that was an unexpected surprise. Since then, they have used the ventilator successfully on about two dozen more snakebite victims, independently of me. That’s a key lesson of global nursing. It’s not about my skills, it’s about helping them with theirs and leaving something behind. Everything you might teach them, every piece of equipment you might donate, has to be evaluated as to whether it will be something the locals can use after you have returned to your own country. If it isn’t then you have to ask yourself whether you are really being useful or not.
What other challenges were there?
I also worked with pediatric burn victims. In USA we refer burn victims to the system of Shriner’s Hospitals, and I think we take these excellent hospitals for granted. Burns are a big issue in South Asia. An inordinate percentage of the adult victims are female, which was a shock. You have to ask yourself how this happened, how these injuries could be prevented. That’s a key role in nursing – to teach and prevent future illnesses. Nutrition was also a factor. The typical diet in Nepal is rice and lentils with very little protein. The lack of protein reserve presents a challenge for wound healing. To live in the culture where you work, will bring you face to face with issues of poverty, gender, and inequality in a way we don’t often confront in the USA.
You seemed to have been really shocked by this.
Most people have heard the term “culture shock.” When you serve as a nurse, you see a part of the foreign country that the usual tourist never sees. That’s universal – the intimacy of nursing as we support people going through a life crisis. To have a nursing experience overseas brings “culture shock” to a whole new level. Living with the people you serve is like being in a movie, twenty four hours a day that you can’t turn off. You need resilience, the ability to maintain a positive problem-solving focus and address the issues at hand. Don’t let little things like coping with a different diet get in the way of your reason for being there.
And when you return?
This does not end when you return. There is a phenomenon called “re-entry shock” of which people need to be aware. I have now met a few nurses who served in Haiti right after the earthquake, for whom their trip was the first time they ever travelled outside the usual tourist bubble. They would say “I knew I did something valuable and dramatic, why was this so unsettling for weeks after I got back?” They were relieved when I explained to them about culture shock and re-entry shock. Even where there is no earthquake, the daily operating conditions in the Low Income Countries are still an awakening, because it is a shock to realize that health care is not valued equally throughout the world. It’s important to have a support group when you return, other nurses who can relate to your experiences and empathize.
What advice do you have for any student who wants to contribute in the field of global nursing?
We can all contribute, even if we never leave home. The AACN has some wonderful resources on cultural competence, including the Tool Kit for Culturally Competent Baccalaureate Nursing Education which is available on their website. Transcultural nursing is one of the cornerstones of ethical practice, and has been with us ever since the pioneering work by Dr. Madeleine Leininger, who coined the term. It starts with such things as learning individual cultural practices, then addresses the needs of the community. Nurses need to become partners with the cultural group they wish to serve, whether it is here in USA or in a foreign country. Every student should cultivate friends from a cultural group other than their own. It’s a simple and effective place to begin to broaden your horizons. Go to their house of worship, eat their food, watch a movie in their language. There is a wonderful poster from Syracuse Cultural Workers which is titled “How to Build Global Community”. Every nursing school in the USA can put the list of ideas from that poster into daily practice. Here in Hawaii we are very fortunate because of the deep crosscultural learning opportunities available every day. There still are places in the USA where this sort of mixing does not happen so easily.
The people from Pacific University in Stockton California have a saying about “resisting the urge to shoebox your experience.” When you return from a foreign country, find a way to continue your global connection. Don’t simply put the mementoes into a shoebox or a scrapbook. In my case, I put this into action by joining the Nepal Society of Honolulu, where we developed a project to send English-language nursing textbooks to schools in Kathmandu. I also wrote a book about my first trip to Nepal, which described the day to day practices of the hospital from a nurse’s perspective. It’s titled “The Hospital at the End of the World”.
Every nurse needs to step out of the comfort zone of retreating to the hospital setting. The hospital is where we try to control every variable and to treat each person as a biological organism independent of their own culture. That is obviously not possible. I think many students tend only to value the inpatient hospital rotations because that’s where the skills are. For a beginner student, it’s harder to see the point of a community health experience, because it’s not as controlled. We all need to connect the issues in the community with the issues of inpatient hospitalization. When you see how the rest of the world lives, it forces you to evaluate your own choices. Nurse should ask themselves how much they contribute to waste of hospital supplies; how much of a carbon footprint they are leaving. To go to a Low Income Country means that you will live in a non-materialistic setting…. How much “stuff” can you do without?
Any last words about global nursing?
Do it. Take the opportunity to use your skills in a global setting. It will help you reconnect with the reason you became a nurse in the first place. You will not become wealthy by contributing to better global health, but you will have the satisfaction of knowing you made a difference.
AACN Toolkit for Cultural Competence: http://www.aacn.nche.edu/education/pdf/toolkit.pdf
Works on transcultural nursing by Dr. Madeleine Leininger http://www.madeleine-leininger.com/en/index.shtml
ON-LINE CULTURAL TRAINING RESOURCE FOR STUDY ABROAD, from University of the Pacific, Stockton California.
The Hospital at the End of the World, Niemczura, Joe. Plainview Press, Austin Texas, 2009. FaceBook fan page to accompany the book, http://www.facebook.com/pages/The-Hospital-at-the-End-of-the-World/46029670798?ref=ts
How To Build Global Community from Syracuse Cultural Workers: