The Evolution of My Atttitude toward megacode scenarios in Nepal

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“Too far from town to learn baseball” as Robert Frost would say.

“And how many members of your team?”

I just spent two days registering people for the August sessions of the signature course of CCNEPal – the 3-day event. More than one person asked this question.

Right now the answer is “everyone in the class is a member of my team”

In 2011 I started this project, experimenting with teaching nurses Advanced Cardiac Life Support (ACLS) skills in Nepal. Okay, it’s a not the “official” American Heart Association (AHA) course by that name – let me make it clear. The course does not include a written exam, and is tailored to the needs of acute care professionals in Nepal. Significant part of the USA course do not apply to Nepal (very few AEDs here, for example, so why bother teaching about it?)

A big part of each 3-day session is small group scenario work, known in USA as “megacode”

And I was thinking about this. I used to do it a certain way. It has changed, slowly, to become what it is these days.

in 2011

when I started all this, I would call forth a group from the class, or ask for random volunteers. They would respond to a scenario while everyone watched. When I did it this way, it was possible for shy class members to lurk in the background and never volunteer.

There was another American RN in Kathmandu, Shirley Evans who teaches the NCLEX review class. When she came, we would divide the group in half. From within each half, a small group would do the megacode while everyone else watched. so – it was “better.”

By the end of 2011 I got to the point though, where some of the Nepali nurses had caught on, and become familiar enough with the scenarios and the ins and outs, that they would lead the small groups. I realized that it was silly to restrict the group leadership only to myself and one other person.


I started off the summer 2013 project with two other RNs – from Canada and Australia. they would lead the groups. they were great. But they didn’t stay the whole summer. And so, I relied on my Nepali friends to help lead the groups, again. Problem was, in Kathmandu all the best ones – Indu Karki, Usa Rai, Anupama Karnajeet,  and Binu Koirala – had jobs, and could not make it every time. time to improvise. When I went to Pokhara, I met Mario Hughes and Sushila Neupane – they helped me as well. Actually, when I think about it, there was a long list of people I pressganged into service.

At Nepal Medical College I also had MDs as co-teachers – which was something new for me. Dr. Gautam Bajracharya, the chief of anesthesia, was a joy to work with. His enthusiasm and knowledge helped me to relax.


This time around I am making it official that I will use the expertise of people within the class. I view these sessions as if I am teaching two simultaneous classes – one for the 25 or so people in the class, and the other for the five or so who are brave enough to agree to be a scenario group leader. To accomplish this, I spend a bit more time at the beginning explaining to everyone just how it works, and when we break up into small groups, the group leaders know that they need to come and join a small huddle to get the updated instructions.

some of the sessions I have been able to have all of the small groups led by a Nepali person, which frees me to give encouragement to all groups and make sure the whole class is going smoothly. after each round of scenarios, each group leader gives feedback in the front of the class, in Nepali, to make sure that every participant “gets it” – which helps overcome the language challenge that some people bring.

When we are practicing ecg, I also ask the fast-learners of ecg to help point the way for the others, so that nobody is struggling with ecg just because of the artificial barrier of language. Over the course of the three days, the small groups can reinforce each others’ learning in Nepali language.


I think this is worth blogging about because it is a concrete example of the way that a person’s teaching approach will change. The content is the same as it’s been, it’s the classroom management strategies to enhance learning that have evolved. These days, adapting the strategy allows me to give up “control” of every single minute element of the class ( not that my classes are ever under control, LOL). I think I gain something more fun.

For my readers:

especially those who teach in culturally diverse settings. I’m curious as to whether you notice the same kind of evolution in your own teaching…..


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 Evolution of My Atttitude toward megacode scenarios in Nepal

  1. Pingback: May 28 report of CCNEPal part three | CCNEPal 2015

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