part 1: tips on how to teach ACLS in a Low Resource Setting June 1 2014 – “notes from the field”

First in a multipart series

(before we start. Buy my latest book. click here to find it on Amazon.)

UPDATE: this is a five-part series. click here to skip to installment five). the style of teaching matters just as much as the content.

I’ve been meaning to write this for awhile, ever since I was contacted by some USA nurses in Zambia, the African country. They wanted to know how I do it, exactly. How do you teach critical care?

What does it take, they wanna know…….

I’m going to share a bunch of things that come to mind. I guess you need to know that I am old. I am as old as Buddha.

I became an RN in 1977, worked in ICU in 1978, started teaching critical care nurses in 1980. I was an ICU/CCU nurse manager for nine years; I pre-date the use of thrombolytics, pulse oximetry, dual-chambered pacing, adenosine, off-pump CABG, laparoscopy, antibiotics for h.pylori, Starbucks, and many other things we now take for granted.  I took my first ACLS course in 1980. I was an ACLS Instructor (now lapsed) and ACLS Regional Faculty ( also lapsed.) I administered an American Heart Association (AHA) Community Training Center (CTC). I have also worked in tertiary centers that did open heart surgery.

I was a cowboy once.

I combine my fifteen years of ICU with fifteen years of college teaching at more than one University. When I look at the training needs, I use my left eye to examine the material, and my right eye to examine how to teach it. What about the third eye, you ask? I use that one to see success or failure of teaching through the lens of metaphysical reality. When I find a better way, I adjust my style or focus.

In other words, don’t attack my qualifications unless yours are better.


First, a short list of anecdotes. Critical care nursing does start (roughly) with the package of skills that are covered in Advanced Cardiac Life Support (ACLS). so, what the status of ACLS? I use Nepal as the place for examples, because well – I am here. I think these are typical of many countries.

-A group of doctors from India is authorized by the American Heart Association (AHA) as a Community Training Center (CTC).  To get this designation, they need to invest in about $20,000 USD of simulation equipment. they come to KTM now and again. they bring their stuff, then bring it back to India when they go. They charge about $265 USD (26,500 nrs, a month’s wages for a Nepali RN) for the training. It seems to me as though there are less than a dozen Nepali docs who are certified in ACLS. There are three that are Instructors, supposedly, but to my knowledge they have never taught an actual class here.

-A nurse who went to school in India (Bangalore) said she took ACLS there and passed. Her cohort included doctors and nurses. In all, seventy percent failed the written exam.

-“You can do a course here, but you’ll never get any Nepali nurse to pass the ACLS written exam,” I was told by another nurse with longtime training experience in this country.

-“You have chosen to teach ecg rhythm interpretation, to nurses who will never be able to do it,” I have been told.

-Supposedly, there was the time an entire team of nurses and docs came here from Indiana specifically to teach an ACLS course. They spent a day trying to get organized, then said “We simply can’t do what we came here to do.” so they packed up and left.

– A doctor who came to teach at one of the best hospitals in Kathmandu later wrote a detailed  list on their blog as to the shortcomings of the ICU. The problem is, I’ve been in many ICUs here, and the one that was being disrespected was among the best ICUs in this country. Over the course of years, that ICU has received an inordinate share of help from other foreign doctors and nurses, prior to that doctor’s visit there.

What do these anecdotes have in common?

First, they tell a lot more about the mindset of the videshi (foreigner) than they do about the actual situation, or about the capacity of people here in Nepal to learn how to do this. Flexibility is called for, and being a content expert is not enough. If you’re going to try this you need to be aware of how to teach it, not just what to teach.

Next, they illustrate the ludicrousness of trying to assume that in doing critical care, the one and only gold standard is the current ACLS course relying on every single item specified for use in USA. Frankly, many of the Nepali doctors who want to take USA ACLS are doing so because they think it will enhance their chances of getting a USA medical residency. And frankly, the success of resuscitation depends on the whole team, not just the doctor. there needs to be broad-based training, not just for a select few.

Also, we are clearly undergoing a paradigm shift in Nepal. For decades, the focus of health was preventative medicine – public health-oriented, maternal-child health oriented, primary care oriented. Now, for better or for worse, new hospitals are being built and equipped with the latest stuff. There is debate as to how sustainable this may be, but – it’s happening. There are too many nuances of the health manpower situation to discuss here, but the bottom line is, we need to find a way to get people trained and stop wringing our hands.

Bullet Points

If you wish to upgrade the critical care skills of personnel in a Low Income Country:

– examine your ideas about cultural imperialism. discard the idea that the American way is the only way to achieve the goal.

– especially disregard the idea that you are somehow superior because you are American.

– don’t simply teach a pre-determined package of stuff unless you have thoroughly assessed what exactly it is that the people need.

– in other words, don’t simply superimpose American training on your students.

– become culturally literate for the area to which you will go.

– learn about the existing educational system from which your new colleagues have sprung.

I like to think I do those things, but am humble enough to get feedback and accept it. Can you say the same?

I think that’s it for now. I will write future blogs in this series. Please share this with any medical or nursing volunteer and feel free to comment!





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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9 Responses to part 1: tips on how to teach ACLS in a Low Resource Setting June 1 2014 – “notes from the field”

  1. Footprints Foundation is rolling out a NICU course for Jamaica later this year

  2. I applaud this piece and agree wholeheartedly. I have been working in and training staff in similar environments for 15 years. The key is to understand the people , how they learn & the current needs. It’s not easy and requires terminal patience but the rewards are vast. I am currently in Zambia and the results we are having are amazing.

    • thanks. a colleague!

      do you have a weblink? please share.

      I invite you to write a longer guest blog essay, if you so desire.

      also, if you are on Skype, let’s chat – I’m joe.niemczura1

      stay tuned for parts 2, 3, 4, 5, and 6.


  3. Thank you Joe, I concur as well. Sustainability of the course content is key to any attempt when teaching. My experience humbled me, as I discovered that the infrastructure needed to support teaching and learning was more important than any content I was bringing to the table. We can all have altruistic goals of nurse-to-nurse sharing of information and support, but “planting the American Flag” and saying, “here we are to teach you” is merely not enough. With the deepest respect for the nurses and nurse leadership from Patan Hospital, as well as the lives we touched as we moved forward with our best laid plans, we soon discovered the basic needs of the people we were learning from superseded any initial goals we brought with us before we got off the plane.

  4. David Bates says:

    Joe, a very thoughtful and inspiring piece – I’m looking forward to part two! My experience is mainly in Africa but the principles are the same. The British Army is going through a transition at the moment much the same as the US and we are both expecting our young men and women to go out into the world and do this. Your philosophy rings true with my own and I am striving to develop a generation of polyglots who will be flexible, agile and adaptable so that they can deploy anywhere in the world to do good. Good luck in teaching! DCB

  5. Hi guys! I loved all the responses. I do think that people who are more steeped in “development philosophy” work on these issues from the beginning, and health professionals are late to the game, mainly because they so often spend years honing technical proficiency. I know that to some extent I am re-stating all the anti-neo-colonialist lingo – but I think it does apply on the personal level in addition to public policy.

    My next entry in this series will take a bit of a turn, since I think I will describe what I learned about the South Asian educational system and the way it impacts my own choices in androgogical strategy. THEN, I will get to some of the actual classroom management techniques I use based on this, and finally my Pearls of Wisdom specific to ACLS.

  6. Pingback: CCNEPal Preliminary report for 2015, late May, part one, just the facts….. | CCNEPal 2015

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