The Truth About Butterflies. duuno why I did this, but – I did.

So I just posted the blog about yesterday’s class, this morning but feel energized right now so I am jotting down today’s while it is still fresh.

As we ended the class Friday, the students had wheedled about dispensing with the final exam.

“Oh no sir, please, have pity on us, we have been taking exams a lot, you don’t know how difficult this is.”

I wish I had pulled out the video camera because it all sounds ever so much more plaintive in the cultured English so well spoken by members of this class. I enjoy the music of the Nepali language and the way that a native Nepali speaker can use English with a touch of UK accent.

As to the request:

No way.

Exam ho!

How could I possibly cancel an exam? You *need* a final exam. It brings closure to a course. Sense of accomplishment and all that. One time at UH I taught the management class to seniors and I made sure the final was substantive. Okay, that particular group hated me… But that is another story altogether. I did it for their own good!

Then as I was on my hike to Bhaktapur (the one in which I never arrived, never did get to enjoy the elusive bowl of excellent dahi for which Bhaktapur is famous), I got to thinking, what type of final would be the best? What should I test?

Here I was, ruminating on and on about the methods of the course….. Why not focus on those – there is so much more to what I have tried to teach, than simply how to read an ECG…

And as I sat under a bo tree on a chautara in a small village, making small talk with five Nepali guys, I thought about how I might use the final exam as a reflective opportunity. I was trying to present methods in support of initiative and self-directed learning after all. The five guys were not the most talkative. It was a hot day and they seemed amused that I would walk for fun.

Now as part of today I met briefly with Campus Chief and I told her “I may have spoiled your students for future classes” – continuing the theme of yesterday’s blog. Her reply was “Mister Joe, my Master’s degree was on this very subject of promotion of self-directed learning. These students are beyond the level of PCL nursing. If what you say is true, then in fact you have fit in with our goals and curriculum very well.” This dialogue caused me to reflect on the support I have received while here….. It’s not all black and white as if my ideas are totally new. The nursing leadership of LNC is guided by people who know what they are doing. An honor to work with them.

In the end, the final consisted of four essay questions.

1) what was the most important thing you learned?

2) how will you use this in the future?

3) what is your opinion regarding the teaching methods? and

4) how will you help other Nepali nurses learn this?

I think this is a fair assessment of what I tried to convey…..the students quietly completed the final. They laughed when I told them not to copy the answers from the student next to them.

Impossible to grade, of course. This was not about a grade.

I asked them to write evaluations, but the students would not. The students said they would compose a joint evaluation letter to the Campus Chief at a future date. “In Nepal, Nepali class, Nepali students, Nepali teacher – this is how we do.”

Chiya break and then to mega-code. Each student demonstrated one-rescuer CPR. Then the teams. In turn, each team did about five scenarios, I put them through their paces. They did fine. Lotta progress. Good vibe.

Until the very last scenario. Here I was, with the team led by Shanti, best student in the group, and Alka, very verbal and assertive. For them, a special challenge.

“The most difficult scenario of all, will be yours, and it will be last.” They waited outside the door. “By the way, you are my favorite group” – they laughed, because they all knew that I said that to every group, every time. “But it’s true!” They laughed again.

Back into the ballroom, I explained to the others that the “patient” was a 21-year-old man, we could not save. In asystole from beginning, never a change in rhythm. I asked for three volunteers, and three stepped forward. “You will be his mother, you will be his sister, and you will be his girlfriend.” The three volunteers said “you know our culture!” A crackle of excitement.

On page 135 of my book, is described a scene of grief. The first time I saw this manifest itself in Nepal, was a shock, but I came to know that there is a pattern of women’s grieving in Nepal when bad news is given. This was an element to explore. I don’t know why I did it, but in the back of my head was something my colleague Patricia Brooks would do at the end of Fundamentals, in which the (fictitious) Mr Keoni Moke, name given to all the mannikins in UH learning lab, had died after all we did to help him all semester. Patricia would guide the UH students through grieving and spiritual care. Patricia had a way to make it real.

For this class, I have gone out of my way to focus on the physiology of cardiac arrest, we needed this focus. Our baggage is left at the door and we focus on the task at hand. But this approach, valid and necessary though it may be, is like teaching entomology through the sole means of looking at butterflies pinned neatly in a museum display case. That is not the truth of butterflies: you will never understand a butterfly unless you have seen them going from flower to flower on a dewy summer morning in a mountain meadow.

And so the team came in. ABCs. CPR. O2 and IV access. Protocol.

And we sprung the surprise. The three grieving women knew exactly what to do; every nurse in Nepal has seen this; every nurse here has experienced this; the mother collapsed, the women interrupted the team, Alka brought them outside to console. They went back in again. The rest of the class stood and gathered to support the mother. Dramatic, realistic, effective.

The resuscitation effort continued bravely, longer than average – after all, patient was only twenty one. And then death. The group had taken this particular simulation to a level beyond simply doing the protocol.

I called the group together, we put “one hand in” as I always do, and as I showed them this week. Then some words about how well they had done, indoctrinating them about professional values. We talked about “breaking bangles,” and they seemed surprised I knew this about Nepali culture. Teary eyed group.

Back to the table under the crystal chandelier. The psychodrama seemed to provoke a heartfelt group discussion, sharing about stress, dealing with families ( who do sometimes get violent), and coping. The experienced students sharing with the newbies.

The farewell afterwards was a bit anti climactic. Students re arranged the room. Campus Chief came up with the Assistant Campus Chief. I spoke, Campus Chief spoke, three students who organized it spoke. This served as a formal chance for all to say farewell and thank you to those who contributed.

I was given a nice card, a T-shirt, a bouquet of flowers and a nifty bandanna. The students agreed to help with my big group as the summer progresses.

When I left I went to the photocopy place and dropped off some things I need for Wednesday. came home and took a nap.

So – slap me when ever I get this “cool.” Tomorrow I have work to do, but the first cohort of baby birds has left the nest…..



About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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One Response to The Truth About Butterflies. duuno why I did this, but – I did.

  1. Pingback: part 4) De-Escalation skills for Critical Care nurses and doctors in #Nepal March 31st 2015 | CCNEPal 2015

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