part 2: teaching critical care nursing in Low Income Countries. “Is there a problem, Officer?”

first – buy my second book. It’s a novel, but it will give you a realistic picture of what it’s like to be in a hospital in a Low Income Country. “Whether the events happened or not, it’s truth with a capital T  

This is part 2 of a series, and maybe it will seem like we’re going off on a tangent. That because we are. I have a list of practical tips for how I go about delivering simulation teaching adapted from USA techniques, so that nurses in Nepal can deliver critical care services. But before the reader runs off and starts implementing the list, the reader needs to ask whether it will fit their situation. After yesterday’s post, I realized how many African readers I seem to have. I haven’t been to Africa, but I think the cultural rules may be different. Educational strategy is highly culture-dependent.

the first rule of effective education:

1. try to purposely deliver it a certain way.

2. see if it worked.

3. if yes, deliver it that way again.

4. if no, swallow your pride and do something different.

5. repeat.


the above is called “praxis.” simple, really.

the meat of today’s blog entry

Here is something I generally resist saying out loud, ever. It is subject to misinterpretation, so I am careful.

When I first came to Nepal, I was supervising a group of PCL nursing students (basic level, equivalent to an Associate’s Degree) on a medical-surgical ward. This was before the now-widespread practice of having an ICU in Nepal hospitals. The first day, a patient crashed, and I worked with a medical student from UK who was also there, to respond. we did cpr and other lifesaving measures. Frankly, I don’t recall the outcome, except that the next day, there was another emergency and we responded again. On the third day? again. Is this going to be a pattern?

Systems thinking

Now, I love responding to emergencies and all, it’s very gratifying if you bring somebody back from the Brink of Doom, and it gets my adrenaline flowing. I feel young again. But above all, I am a systems guy, and something was not working. We shouldn’t be getting to this point. This thought occurred to me: where did the regular nurses go? and a quick check revealed that, as soon as the patient deteriorated, the nurses found something else to do, someplace better to be. Or, they did things that seemed pointless, for example, not using the ambu bag themselves but handing it to the family member and using the opportunity to teach the family how to ventilate the patient. (while their loved one was arresting).

Conversation with Nepali doctors, over and over again

I meet Nepali doctors both in Nepal and in USA. Lots of Nepali doctors have been to USA and come back, so I am not the only one who compares and contrasts the two systems. Here is a conversation I have had about fifteen times or more since 2007.

me: “I teach nurses when I go to Nepal.”

Nepali doctor; “That’s nice.” (warily. Not really warming up to me.)

me: “specifically, I teach about emergency response.”

Nepali doctor: (getting a bit more interested) “Oh really. I don’t think they do it very well there. I don’t know how to get them to do it better.”

me: ” yeah, what I have noticed is, the nurses have never been properly trained. They don’t do well to predict an emergency and prevent it, then they let fear get the better of them and they don’t know how to be helpful.”

Nepali doctor: (enthusiastic) “Yes! yes! that is exactly what I have noticed. If that’s what you work on, I need to contact all my friends in Nepal and tell them about you. Everyone knows we need to fix this!”


Next thing you know, I get invited to teach at some new place.

So, I spent some time discussing why this might be. what were the barriers to an effective emergency response?

First and foremost, it’s simply not taught. the PCL curriculum in Nepal is based on teaching women to be “staff nurses” in what we would call a “Functional Model” of nursing service delivery. Hot Tip: if you are interested in health policy for nursing in any low income country, and you don’t know what “functional nursing” is, you have missed a major piece of what you need to know. In the functional model, the smallest possible number of nurses are hired, and they are task oriented, because they can barely get through the tasks. This does not allow for critical thinking or for improvisation when there’s a rapidly-changing situation. It’s NOT because the nurses or students lack intelligence. the system is stacked against them.  I feel like I have to be clear about that, because there will be people who think I am disrespecting the intelligence of the people I work with. I am bracing myself to receive angry emails.  Nothing could be further from the truth.

Why not start at the top?

Why do they do functional nursing? Well, because somebody told them to do it that way! Nursing school curriculum is dictated by the central government agency, CTEVT, and they pretty much give the faculty the actual lesson plan, there is not much room for flexibility. In their defense, it took a lot of coordinated work the develop this level of educational consistency across the country, and nobody should dismiss the efforts that have gone before.  And it would take years to lobby for a whole new area of content, in the curriculum. The first step is to convince the educational bureaucracy that there is a problem. I’ve been teaching critical care nursing since 1980, in USA. I think I am an expert.But realistically, if I wrote a letter to CTEVT, they would ignore me.

I could hear them saying “One more Videshi, telling us what to do. He doesn’t know how hard we worked to get to this point.”

yeah, If I were them, I’d be irritated too!

Just do it (the Nike slogan)

On the other hand, if hundreds of Nepali nurses and doctors all of a sudden started talking about a better way to do things, they would eventually become impossible to ignore. And so, in 2011 I decided I would address this by just teaching the material to nurses, one batch at a time, to lay the groundwork for a groundswell of public opinion.  Sort of like Malcolm Gladwell’s Tipping Point. I don’t want to get all intellectual on you, but  on Mr. Gladwell’s web page he says:

The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.

I’m not going to tell people there is a better way. I’m going to show them a different way, and people can decide if it’s better.

And so here is conversation number two:

me: “here’s what to do to respond in such-and-such a situation.” 

groups of Nepali nurses: “Oh My God, I always wanted to know this. I read about it in a book, but there was nobody to show me”

me: “well here it is.”

groups of Nepali nurses; ” As soon as I get out of class I am going to share this with friends at work.”

me: “good.”

groups of Nepali nurses: “we can’t wait until the next class – what will you teach then”

Me: “come back and you will see”


and finally, the one magic ecg handout.

I guess I should tell you, in USA we used a very specific handout that got worked on and perfected, for decades. In 2011 I brought it here and gave it to the class.

The following week, a nurse from one of the bigger hospitals came to me and said “I knew this handout was something we needed, immediately. When I got to work, we photocopied 200 of them, and now it is being used by all nurses and doctors in every area of our hospital.”

Just one more reason why I do this.

tomorrow: the elementary education system of Nepal, and why every wannabe international trainer has to spend a day in a kindergarten.




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 part 2: teaching critical care nursing in Low Income Countries. “Is there a problem, Officer?”

  1. anita bhattarai says:

    i want to join the training provided by ccnepal 2014

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

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