Blog editor’s note: Ms. Gaynor Sheahan is a nurse from Australia who has spent time working and teaching in Nepal. She wrote this paper as a graduate school assignment for Monash University. There are people within Nepal writing about nursing education but very few of such essays make it to the wider circulation of international nursing community. I requested that she send this for posting since it addresses a knowledge gap.
Gaynor Sheahan Bio
Presently in Melbourne, Australia. working as Clinical Nurse Specialist in critical care areas, with inservice education portfolio Post Grad student on Master of Nursing Course (due to complete end of 2013) Post Grad Certificate in Emergency Nursing Intensive Care Nursing, Entry into Specialised Practice Accident and Emergency Nursing Certificate. Certificate in workplace training and assessment.
Ms. Sheahan Lived in Nepal for seven years, and worked as volunteer nurse educator at Patan Hospital. Introduced the first system of triage in Nepal at Patan Hospital Emergency Department in 1998. In 2009 and 2011, she taught a two-week “Introduction to Critical Care Nursing Course” at Tansen Mission Hospital, Palpa district. Her email address is firstname.lastname@example.org
Nursing education in Australia could be considered to have undergone a revolution in recent decades with the transfer to tertiary level institutions, and the development of nursing theory and research leading to evidence based nursing practice (Russell, 2000). The move away from didactic teaching to innovative teaching methods such as developing critical thinking, problem based learning, peer-to-peer education, interprofessional learning, student led learning, reflective journals, and use of interactive media are the subject of numerous research studies assessing the impact on improved learning outcomes and clinical experience. Continuing education, professional development, and competency requirements for qualified nurses are also areas where change is taking place (Cowan, Norman, & Coopamah, 2005; Jarvis, 1997). These changes reflect the increasing complexity of nursing and the demand for highly professional nurses. For less developed countries however the development of nurse education has been slower and more difficult. The reasons are complex but poverty, and its associated impact on health, education and development must be included in any consideration. Conflicts, war and displacement of people groups are important additional factors.
Nepal is perhaps more famous for being home to the world’s highest peak, Everest, and for trekking, than it is for its poverty and associated poor health outcomes. Nepal has also been in the news internationally for other reasons: the massacre of its royal family in 2001, and for the decade long civil war with a Maoist insurgency, which has only recently settled into a fragile peace in 2006. Nepal has a relatively young national health system, having been closed to the outside world until 1950 when the first steps were taken
towards a health care system (Gubhaju, 1991; Maxwell & Sinha, 2004). In contrast many countries in the developed world have had some form of universal healthcare and associated nursing education for centuries (Nelson, 1997). In this essay the history of nurse education in Nepal, and the current problems affecting further development of nurse education will be discussed.
One of the poorest and least developed countries in the world, Nepal is a country of nearly 28 million people. Landlocked and bordered by two much bigger and richer neighbours, China and India, Nepal has no railways and few roads. Those roads that do exist are poorly maintained. The poor road infrastructure and the mountainous geography isolate the rural areas and are significant contributory factors to the difficulties in delivering, and seeking, health care (Gubhaju, 1991). 55% live below the international poverty line (Unicef, 2010b). The poor living in rural areas are particularly at risk from the many health problems besetting Nepal: epidemics of infectious disease; natural disasters such as floods, landslides and earthquakes; and malnutrition. Rural populations have also borne the worst effects of the civil war with a conservative estimate of 12,000 Nepalese having been killed between 1996 and 2006, and tens of thousands displaced (World Health Organization, 2007). The decade long civil war formally ended in November 2006. In 2008 the country voted in a Constituent Assembly, with inclusion of Maoist leaders for the first time in a coalition government (World Bank, 2010).
Before 1950, Nepal was isolated from the outside world, with no public health programs and few hospitals. There were fewer than a dozen Nepali doctors and no Nepali nurses (Gubhaju, 1991). The average life expectancy in 1950 was 26 years (Hagan, 1961, as cited by Maxwell & Sinha, 2004). Two Nepali nurse candidates were sent to India to train in 1952, and there were a few Indian trained Nepali midwives (Shahi, 2005). There were no universities and medical education did not exist within the country (K. Regmi, Regmi, & Shahi, 2009). Most health care was provided by family members, with faith healing the most dominant medical system, provided by healers known as ‘jhankri’. The Ayurvedic system of medicine, in existence for centuries, was practiced throughout Nepal (Gubhaju, 1991; Maxwell & Sinha, 2004). Even as recently as 1983 there were 113 Government supported Ayurvedic dispensaries in the country. Tibetan medicine and homeopathy practitioners were also consulted, although they were less prevalent than jhankri (Streefland, 1985).
The first professional nursing school was established in 1956 in Kathmandu, with 15 students for a 3-year hospital based training, resulting in a Certificate of Nursing (Shahi, 2005; Thakur, 1999). In 1959 a second nursing school, the Shanta Bhawan School of Nursing was established, run by a Non-Government Organization, The United Mission to Nepal. Between 1956 and 1971 313 nurses were trained. In 1972 the Institute of Medicine, (IOM) Tribhuvan University, took control of nurse education in Nepal with the New Education System Plan. Nursing in Nepal was still very much focused on hospital based health care, at Proficiency Certificate Level (PCL) (Maxwell & Sinha, 2004; Shahi, 2005; Thakur, 1999). In 1976 Post-basic nursing education was introduced by the IOM. Initially this was developed as a Diploma of Nursing course but became the foundation of the Batchelor of Nursing (BN) program (Maxwell & Sinha, 2004; Thakur, 1999).
A major review of nursing education took place in 1987 and the concept of primary health care (PHC) was introduced into the curriculum, reflecting global trends for delivery of health care in developing countries. PHC was a major step forward in matching the health care needs of the population, which was mainly rural based, with the kind of nurses graduating from nursing schools, with less emphasis on hospital based curative treatment. Nurses began to train rural health workers and traditional birth attendants, and students were sent to work in remote areas for community experience. This new curriculum also attempted to improve nursing practice with the use of nursing research, and to develop the leadership skills of nurses. The IOM established the first Master of Nursing (MN) course in 1995, with a first intake of 4 students (Bentley, 1995; K. Regmi, et al., 2009; Thakur, 1999).
The development of nurse education has been slow however. During the 1980’s and ‘90’s many nursing faculty were recruited soon after graduation and had little clinical experience. What experience they did have, was mainly hospital based which was out of step with the new emphasis on PHC (Ogilvie, 1998; Thakur, 1999). The Nepal Nursing Council (NNC) was established in 1996, responsible for reviewing the nursing curriculum and examination system, nurses’ code of conduct, to maintain a register of nurses, and with responsibility for accreditation of teaching institutions. The NNC also investigates complaints made against nurses (Maxwell & Sinha, 2004; Nepal Nursing Council, 2011) .
By 1999 there were eight nursing campuses in Nepal and approximately 3,000 professional nurses for a population of similar size to Australia. Although there was a need for 160 nurse educators to achieve the stated teacher-nurse ratios set by NNC at the time, the number of teachers actually available was 115. Other issues of concern in 1999 were: the ratio of nurse to patient, especially in rural areas; the number, qualification, and experience of the teaching faculty; and the preference of qualified nurses to work in private rather than government facilities (Thakur, 1999).
The nursing courses offered in Nepal today are based on a two tier system: a Certificate of Nursing, a 3 year training program requiring education to the 10th grade (approximately 16 years of age); and tertiary level courses. The Post Basic Program in Nursing (BN), conducted over 2 years, requires previous completion of the Certificate in Nursing and at least 3 years experience. The most recent program in nursing, the Batchelor of Nursing Science (BSc), started in 2005 with 20 students. The BSc is a direct entry course on satisfactory completion of the School Leaving Certificate at the end of 12th grade (approximately 18 years of age), conducted over 4 years (World Health Organization, 2010). Currently there are 16,171 nurses registered, plus 17,072 auxiliary nurse midwives and 675 foreign nurses (total 33918) (Nepal Nursing Council, 2011). Most registered nurses are PCL trained (Maxwell & Sinha, 2004)
In “Global standards for the initial education of professional nurses and midwives” the World Health Organization states that the future of nursing and midwifery education will depend on the quality of education at the degree level. Research has shown that “a more highly educated nursing workforce not only improves patient safety and quality of care but saves lives” (2009, p.10). A future goal according to WHO, and Maxwell and Sinha (2004) referring to Nepal, would be to encourage continuing education and professional development in accordance with worldwide education trends. Although there is a shortfall in nursing faculty in many countries, nursing schools must produce graduates who demonstrate “critical and analytical thinking” (World Health Organization, 2009, p. 21).
Accurate data as to the current state of Nepal’s nurse education system is difficult to find. What is available is limited, with little research on nurse education in Nepal published in international peer reviewed academic journals. This is perhaps a reflection of the long civil war and its aftermath, continuing political instability, and Nepal’s struggle to overcome its poor economic state in a world experiencing a global financial crisis. The main challenges facing nurse education in Nepal today, according to research and journal articles that are available, will be discussed below, summarized as: lack of experienced nursing educators, lack of critical thinking, gender and cultural issues, a lack of resources, heavy reliance on certificate level nursing staff, a need to further develop nursing education at tertiary level institutions, and a lack of adequate supervision and standardization of private education providers and the nursing courses they provide.
Joe Niemczura, a nurse educator from the University of Hawaii, interviewed Radha Bangdel, the Campus Chief of Lalitpur Nursing Campus (LNC) in Kathmandu, Nepal, in July 2011. Lalitpur Nursing Campus is respected as one of the oldest nursing schools in Nepal, having originated from the Shanta Bhawan nursing school (Maxwell & Sinha, 2004). Bangdel studied for her Master of Education in Thailand. She describes the challenges of nurse education in Nepal today as she sees them: for LNC alone, of 32 nursing faculty positions only 27 are filled and there is a significant lack of resources and multimedia equipment. A videoed tour of the “demonstration” rooms within LNC confirm the need for more up to date equipment, manikins and teaching resources (Niemczura, 2011a, 2011b).
Nepali nurses have often experienced only a rote learning, didactic, teacher led educational system prior to entering nursing school (K. Regmi, 2008). The quality of education in Nepal is generally poor, with high repetition and dropout rates. “Only just over 50% of teachers are trained, they rely on simplistic teacher-centered classroom practices” (Unicef, 2010a, p. 1). Nepali nurses generally follow set routines and procedures with a task orientated focus and do not tend to question treatment decisions or the medical management of patients. Critical thinking is not encouraged, and problem-solving skills are not well developed. Nurses do not generally see being a patient advocate as part of their role. The strict hierarchy with particular respect shown to nurse educators and doctors mean that it can be seen as disrespectful to question a teacher. To admit to not having understood something is tantamount to saying that the teacher has failed to teach you properly (Wetzig, 2004). The traditional educational system from which nurses have come may be at least partly responsible for this highly prescribed functional nursing model and for a lack of skills such as critical thinking.
Gender and cultural issues have been, and continue to be, significant issues in nurse education in Nepal (Maxwell & Sinha, 2004). Nepal is a deeply patriarchal society (Maxwell & Sinha, 2004; R. R. Regmi, 1999). 27% of males in Nepal between the ages of 15 – 19 think that husbands are justified in hitting or beating their wives in certain circumstances. 24% of females in the same age group agree (Unicef, 2010b). Before 1987 only women were admitted to nursing courses. Between 1987 and 1992 men were admitted but Nepali cultural norms were such that it was thought that one male student “can dominate an entire class” and that men were “less caring” than female nurses (Ogilvie, 1998, p. 75). Other concerns were that men might see themselves more as doctors than nurses and be reluctant to provide physical care to patients. However, some nursing faculty suggested that men were effective in community health situations and that more men as nurses would improve the status of nurses in Nepal. During this time there were no male faculty and none were students on the bachelor of nursing courses. In 1992 it was decided to stop admitting men to nursing courses (Maxwell & Sinha, 2004; Ogilvie, 1998). Nursing is still an exclusively female profession in Nepal today although it may have a higher status than it once did with families going into debt so that a daughter may go to nursing school (Maxwell & Sinha, 2004; Niemczura, 2011b).
The increasing number of institutions offering nurse education in Nepal has led to concerns about the quality of courses provided, such as: a lack of uniformity of programs; a lack of minimum standards; inadequate teaching of basic science and communication skills; and a lack of specialized nursing courses (Shahi, 2005). Shahi also recommends that there should be a minimum entry level of 12th grade education to both BN and BSc nursing programs, and electives offered to provide wider options.
Current international research in nurse education examines the use in developed countries of highly technical equipment and resources, such as simulation laboratories and interactive media, which require computer systems, software and equipment, Internet connections and reliable infrastructure for support. The financial cost is often prohibitive in countries such as Nepal, already heavily dependent on international aid. Only 2% of the population in Nepal has Internet access (Unicef, 2010b). Technical support, maintenance, repairs, and an irregular electricity supply can also be significant problems. Load shedding, where certain areas do not have electricity for parts of the day, is widespread. In the Kathmandu valley the current load shedding is for 2 hours a day (Republica, 2011) but can be as much as 16 hours a day.
Research examining relatively inexpensive ways of improving nursing education in Nepal, such as possible curriculum changes, different teaching strategies, and interprofessional learning (IPE) has been conducted however. Regmi, K., Regmi, S., and Shahi (2009) used interviews and focus group discussions with nursing students and nursing tutors from various educational institutions in Nepal to review the present 3-year undergraduate curriculum and to compare to current curriculum theories/models. Appropriate strategies to improve nursing education in Nepal were also explored. The curriculum was first developed in 1987 and revisions were made in 1987 and 2007, with changes reflecting a move away from a subject-centered focus to student-centered, and to encompass PHC strategies. K. Regmi et al concluded that, although significant progress has been made in nursing education in Nepal, challenges remain and must be addressed in order to improve the quality of nursing education and practice: a lack of appropriate teaching-learning methodologies; the “tutors’ incompetencies” (K. Regmi, et al., 2009, p. 52); poor education policy; the need to further develop student-centered learning and participation, using approaches which focus on problem-based learning; increased clinical experience to narrow the gap between theory and practice; and a greater focus on evidence-based learning. The development of a system to improve the performance of faculty by evaluation of learning outcomes was also suggested. Self directed learning and reflective learning were considered to be important ways student nurses could be introduced to the concept of ongoing professional development (K. Regmi, et al., 2009).
An IPE study, described as a collaborative learning situation where two or more professional groups learn from and about each other, examined the attitudes of 30 final year medical students and 30 third year undergraduate nurses toward IPE through questionnaires and focus groups. Some of the problems identified were: the differences in educational attitudes between medical and nursing students, and a significant gap in
teaching-learning. The authors concluded that the benefits of IPE in this study were: improved communication skills in relation to both colleagues and patients; the development of a team approach towards patient care; and increased understanding of each other’s position in regard to educational and clinical situations (K. R. Regmi & Regmi, 2010). IPE a cost effective way of sharing resources and training, especially in developing countries such as Nepal and ultimately could deliver better health outcomes (K. R. Regmi & Regmi, 2010; Yan, Gilbert, & Hoffman, 2007).
Manisha Nair and Premila Webster (2010) conducted a literature review into published research in the last 10 years on education for health professionals in less developed countries such as India, classified as Emerging Market Economies (EME). Some of the conclusions reached echo many of the problems identified in the above Nepali research: outdated curriculum and teaching methods; the unprecedented growth of private medical and nursing educational institutions, mostly unregulated; the quality of education provided; the shortage of educators; and the need for a standardized accreditation system (Nair & Webster, 2010). It would not be unreasonable to conclude that these problems may be worse in Nepal compared to EME given that Nepal is not yet developed enough to be considered an EME.
In conclusion, health statistics for Nepal remain dire: life expectancy in Nepal is 65 years for men and 69 years for women (Australia: 80 years for men and 84 years for women, one of the highest in the world) The probability of dying before the age of 5 years is 48 per 1,000 live births, with most deaths due to diarrhoea, birth asphyxia and pneumonia (Australia: 5 per 1,000 live births) The total expenditure on health per capita is US$69 (Australia: US$ 3,383). Maternal mortality ratio is 380 per 100,000 live births, one of the worst in the world (global average 260 per 100,000 live births, Australia: 8 per 100,000 live births) (World Health Organization, 2011a, 2011b, 2011c). In a country where 80% of the population lives in rural areas the concentration of the health workforce and health facilities is significantly weighted towards urban areas (Maxwell & Sinha, 2004). Understandably, priority is often given to those programs that will have an immediate impact on health outcomes, such as reducing the maternal mortality rate and deaths of children before the age of five. It could be argued that longer-term health goals, such as improving and regulating nursing education have had to take a lower priority.
However, the development of nursing education in Nepal in less than 60 years can be viewed as remarkable, especially when considered against a backdrop of an impoverished economy, rapid social change, civil war, and political instability. Nepal has progressed since 1950 from a feudal, medieval country closed from the rest of the world to a democratic nation, with a developing health system (Maxwell & Sinha, 2004). Nepal is a country at “a crossroads, an open moment” in its history, the next few years considered to be critical, with long-standing development challenges at a time of global economic crisis (World Bank, 2010, p. 1). There are no easy solutions to the challenges within nursing education today in Nepal, at least some of which depend upon a stronger economy, political stability, an improved, regulated educational system, and significant infrastructure. Encouraging signs with the growth of Nepal specific research and tertiary level education, and the increasing number of nurses undertaking Masters level education allow some optimism that nursing education in Nepal will mirror the changes that have already taken place in developed countries over the last few decades (Maxwell & Sinha, 2004). The most effective immediate changes however may be those that involve the least expense and that could be adopted in Nepal today without waiting for political and economic stability, such as curriculum changes, IPE, and the use of innovative and creative teaching strategies. Cultural factors, such as gender and status in a patriarchal society may however be important in the success of any changes.
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