All #Nepal nurses and MBBS docs need to read this carefully before viewing the videos of violence against health care workers in Nepal.
(note: in the video, the scenario was a surprise to the responders. The woman wearing the turban is one of the teachers and she does know the scenario. Focus on the family interactions, not the execution of protocol).
CCNEPal is the name for the courses taught by Joe Niemczura, RN, MS of USA when he is in Nepal. Joe was teaching at a PCL nursing school in Nepal since 2007 and there he learned that Nepali nurses and doctors are not taught to deal with emergencies the same way that USA nurses and doctors would be, so he set out to change this. He developed a three-day course (three for nurses; just two days for MBBS docs) to go over the Advanced Cardiac Life Support skills. He adapted the one from USA to fit the needs of Nepal.
Is thrashing included?
These needs included “What do when the patient party is unhappy with an adverse outcome and threatens to thrash the doctor ( or actually does thrash the doctor)”
This happens. It happens throughout Nepal, and Joe was asked about it everywhere he went. It’s a dirty little secret of Nepal health care. Some docs and hospitals deal with it better than others, and it is unfortunate that somehow the doctor gets blamed if it happens. An angry reaction from the “patient party” is not avoidable, but the skills to keep it under control need to be more widely taught in Nepal.
Lifting the veil of secrecy
Until spring 2015, this was called “the secret scenario” since there was a certain element of surprise involved, and Joe always asked people not to tell others about it unless they had already taken the class. Because this part was a “secret” the main way that people learned about the course was via word-of-mouth from people who had already taken the course. The secrecy allowed the course to possess an element of suspense and showmanship that left the participants with the feeling of having accomplished something amazing.
That was not enough.
In academic terms, Joe’s assessment was that the Nepal MBBS education needed to emphasize “situational awareness” more than it did. The MBBS docs are taught a methodical system of assessing their patient that is not helpful in a life-threatening emergency. Also, the focus is on patient physiology but it needs to encompass the entire microcosm of possibility that exists in an emergency room.
A recent intern who took this course said (paraphrase)
“Til now it hadn’t occurred to me that I would be directing everything – not just the resuscitation, but the whole team of helpers and also the hospital security and maybe even the police if there was a problem. From now on, I will be much more able to think about pro-actively enlisting the aid I need from all possible directions, not just trying to rely on myself.”
Joe knew he would be returning to USA in Summer 2015. And so, this spring he started to post more specific blogs and videos. Joe no longer followed the secrecy rule. You can find them on YouTube.
There are some warnings about the videos and blogs.
First, the scenarios are acted out, not real, though at times the actors and actresses express deep pain or grief.
Next, sometimes people laugh, which may seem paradoxical. Be advised, any mental health professional will tell you that laughter can be a sign of anxiety, and does not imply disrespect.
The actors portraying the wife and members are selected the day before, based on their acting skills displayed in more mundane scenarios. They are given time to research and prepare. They bring their own costume ( making it more real and more fun). Nobody forces them to be in the role.
Third, we do this because simulation learning is a critical mode for adult learners such as interns, MBBS docs and nurses. It is an acceptable substitute for actual experience. There is an immediacy that can rarely be achieved using sit-down-and-take-notes lecture style.
Finally, the debriefing is critically important. When we do these as part of the class, we create a methodical build up to mentally prepare the participants to deal with emotionally-laden material – which may even trigger issues that are personal to them. We don’t just spring it on them and we always give people time to frame it in the proper context. That is handled during the debriefing process. This too, is new to Nepal.
Here is the link to the video. Click here.
Here is the link to the first ( of two) videos that show the debriefing. click here.
Here is the link to the second debriefing video, which highlights many practical tips in Nepali language, for dealing with this problem. It’s long, but worth it.
CCNEPal wishes to acknowledge the support of Chitwan Medical College for this program. CMC is on the cutting edge of MBBS education in Nepal, and provided a living laboratory to explore the best ways to teach this content. CMC was the first MBBS program in Nepal to make this program mandatory for all final-year MBBS students (just before internship year). CMC has an expert staff who can teach this.
Nationwide throughout Nepal
CCNEPal has some specific conclusions
1) the training is effective and is needed by MBBS graduates during their internship year. They should not wait until the post-graduate time to get this training.
2) the skills of situational awareness are needed in mass casualty triage, and natural disaster. The MBBS docs will be on the front lines of this.
3) the program needs to scale up to include all medical schools and nursing schools. There needs to be a funding mechanism to support this during the scale-up phase.
There are twenty MBBS schools in Nepal. CCNEPal has worked with four of them. We believe that each of these needs to develop the expertise to teach this content, both the ACLS portion and the situational awareness portion, at a level of the curriculum earlier than at present (in fact, most schools do not teach this at all).
Join the campaign!
As of July 2015 we are re-evaluating how to move forward. Spreading the awareness is always a good step.
Here are things you can do:
Share this blog, and the videos, with as many people as you can.
If you are a medical student, ask your medical school about developing this.
If you have taken the course already and seen how the scenarios work, start using scenario-based education at your workplace.
We need to educate policymakers and leaders. If you can think of ways to do this, contact us.