“Joe! Stop and Smell the Incense!”

High Water Update

Today the Bagmati River receded about a foot, but the rains continue intermittently, so the hundreds of squatters living in bamboo and blue tarp shacks on the river bank at Thapathali are still living a tenuous existence.

This week and next is my last relatively light period, before a three week stretch in July. August 2nd, I fold up my tents and steal in to the night.

Wednesday Course Update

This Wednesday June the 29th we introduce the last of the ECG rhythms from my “Atlas” – ventricular rhythms such as PVC, VT and VF. And we’ll talk about the finer points of defibrillation. The class will tiptoe through basic cardiac pacing as well. Most places do not insert pacemakers, even here in KTM. And then of course, more mega-code.

There are a couple of social events in the run-up to Fourth of July, then Independence Day itself. In the past there has been a party for expats at the US Embassy – if there is one this year I will attend. Every Fourth of July here has been memorable. I am a sentimental softy for such things.

I will go to Bharatpur July 10th, 11th and 12th;

I will teach at Orbit MBBS the 17th, 18th and 19th;

And I will teach at a classroom loaned by a hospital in Old Kathmandu July 24th, 25th and 26th.

Twelve all-day sessions in a month of thirty one days.

This last cohort in Old Kathmandu is new; it will be open to employees of the hospital that owns the classroom, but my main reason for seeking this out was to make my training available to any person who was unable to make the eight week cohort, camp followers and stragglers of all types. My plan is to re-contact the persons who were unable to make the Big Wednesday class.

During this period the Wednesday Juggernaut will roll along, which is how I end up with three weeks of four-day-in-a-row stretches.

I announced this on FaceBook and I got a note from a friend who wrote “Joe! Stop and smell the incense!”

ROTFLMSS. As a writer I love a twist of phrase. Nancy Leigh Wendling Harness,RN, NP,  is a wonderful writer, IMHO and I recommend her books on Global Nursing. Google her or go to Amazon dot com.

The fact is, I am having waaaay too much fun. I can rest when I am dead. When you love what you do, you will never “work” a day in your life. As a writer I easily fall into cliches.

There will be four or five days off at the end, in which I will do some kind of multi-day adventure that will be more “touristy.” I am not sure just what that will be, since I try to do touristy stuff every day for a little bit, anyway. A quick trip to the summit of Everest would be in order; maybe I will settle for the one they call “Rum Doodle” – more my speed. Stay tuned.

Taking the long view, there will also be ten months to recuperate from the summer of 2011 trip, before I come here again.

“Recuperate” may not be the best word. I am in a great head space – nothing to recuperate *from*. I will take a month or two in which to not think about Nepal 2012, then get going again.

And the Long Term Follow up is….?

I suppose I need to think about the “what next” question, as in, “how do you follow up on this?”

This has been the subject of discussion around here, and in particular I enjoyed some points made during the meeting with the doc that I had just yesterday.

He said:

“The population of Kathmandu Valley is now five million. We were waiting for the government to act and build hospitals. That is too late. The private sector has now stepped in and is building them”

I said to him:

“I could have planned my own project by going through the regular channels, corresponding with government agencies and NGOs, seeking funding, and awaiting permission. But then it would have never happened.”

The two approaches are parallel.

I realized that this doc has solved “The Riddle of Steel” as have his colleagues.

The nursing situation in Nepal is intertwined with marriage, career and the role of women (isn’t it everywhere?) I think I can easily write a whole blog on the dowry system and the role education plays in arranged marriages, and the nursing workforce, here. Arranged marriage as an institution, is alive and well in Nepal. The cultural factors I observed at yesterday’s wedding reception have a direct parallel in the nursing workplace.

Now, he also had a view of the Brain Drain, in which Nepal’s educated youth are fleeing the country. He pointed to the resurgence of India as an example of the “reverse Brain Drain”, and thinks that a similar homecoming-with-skills could happen here.

He also told me I should not discourage nurses from wishing to go overseas. “It gives them a goal, and keeps them working at self-improvement, which is highly desirable. Most will not actually go overseas, but those that do serve to motivate their colleagues to study harder here at home.”

Note to self: If the US economy ever changes and the US visa system becomes favorable, there are a bunch of South Asian entrepreneurs ready to move in and supply nurses. In the meantime, “EU, UAE, and Japan have wide open markets.”

As in all discussions this summer, we talked about the way the Nepal educational system for nurses is structured and how it adapts to change. The long-established schools such as LNC or Bir have the means by which to adapt to new paradigms, but there are now fifteen schools planning to offer a “B Sc” degree in Kathmandu, many of these new.

There will continue to be a period of great transition here. Nobody knows where it will go. The element of free enterprise, and the idea of “civil society” is still new to this formerly centrally-directed Himalayan Kingdom.

From what I can see, a major problem in Nepal is lack of faculty who can teach in the new way, teach to a paradigm of something different than functional nursing. In the customary PCL program, the so-called faculty are often recent PCL graduates themselves, and they teach the way they were taught. It “works” to transmit what they know – but not when new things need to be absorbed. Change comes slowly.

Presently, the B Sc programs are lumped in as “observation only” experiences and the graduates of such are not as competitive in the job market. The schools are all moving toward improving their learning labs and simulation experiences. LNC has already asked me to help them find grant funding to upgrade theirs – since they are part of T.U., they are quasi-governmental and don’t have the entrepreneurial flexibility some of the newer schools bring.

I have known from the beginning here that my approach, while seemingly traditional (whiteboard, markers) would model a way of doing things (problem-based, group work, interaction) that was new here. I am told by many people that yes indeedy, I am different. General recognition that more of my kind of approach is needed.

So – the goals would appear to be two-fold.

FIrst, to continue to introduce new concepts of nurse’s bedside decision making and use of teamwork. Critical care is the vehicle. I can use it to “Trojan Horse” my teaching methods.

Second, to find ways to help transition Nepal’s nursing systems away from functional nursing to a more flexible nursing model.

The logical long range target method is for Nepal to establish graduate schools, and get some “M Sc” nurses out there. These folks are still, unfortunately, booking it on out of here as fast as they graduate. Ouch.

So – this is what I am thinking, and no, I don’t have a preplanned idea as to how I can contribute, other than keep doing what I am doing… Any ideas out there?

It’s still a muddle, but I can use the remaining time to build relationships, meet people, and lay the groundwork for the future……..

If you have a response to this half-baked set of ideas, please post to the blog – let’s get a dialogue going –



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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2 Responses to “Joe! Stop and Smell the Incense!”

  1. I know what you mean when you say you are having fun as you work; it is so rewarding when doing good deeds is an enjoyable adventure. Maybe not a vacation, but close! I realized as I headed back to the Port-au-Prince airport after 10 days in Haiti that I was recharged. It was an interesting feeling.

    I’d like to hear more of your thoughts on training capacity. You say
    “From what I can see, a major problem in Nepal is lack of faculty who can teach in the new way, teach to a paradigm of something different than functional nursing.”
    Perhaps you’ve already addressed this, but I’d love to hear about what your thoughts are in regards to building this capacity – are you mentoring people so that future training will be offered once you leave?

    • Thank you for this. This is a country of twenty six million people, with two dozen nursing schools in the capital city where more than four million people (say say it’s five) live. there is so much that happens in all the places that for me to say I am having a personal impact on nursing education would be – difficult.

      two tracks here. first, the critical care education piece that I add is in fact being done at some of the better hospitals in KTM – for example, Gangalal Heart Center here seesm to train their nursing staff very well. But nobody has offered any kind of training to the larger population of nurses outside their own bailiwick. they ar eonly training at the narrow end of the funnel. Its easy to say that this is because of cost issues.

      Next, in my Wednesday critical care course, I have about ten students who are teachers from the various schools – I have told them all to expect a “clean copy” of all course handouts so they can start to use them in their own teaching. One hospital sent a person to this class so she could turn around and teach this content there.

      Finally, in the BN class from LNC there was one particular student who possessed several years of ICU expereince and who had the leadership skills enough that I think she truly could make a good teacher for this. She spoke Nepali too! i hope to use her to run some of the mega-codes in future, and i think that in future times it would be great to get her set up to do this – but as to how, is the question.

      As I said in the posting, if i was seeking to only go for the Big Audacious Goal, the one where I transform the entire country to a new paradigm – I would still be sitting in my office in Honolulu waiting for the phone to ring. The best I can do is to provoke people into thinking of different wasy to get things to happen.

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