The Three-legged Stool of Global Health Nursing – for October 15th in Boston!

Nurses: A Force for Change: Improving Health Systems’ Resilience

above is the title of the Oct 14th and 15th 2016 meeting of Boston’s Global Health Nursing Caucus (in Boston of course!) and the event can be found at: It’s co-sponsored with SEED Global Health.

Lightning Talks between 11 and 12:30  the 15th

They’ve made space for “lightning talks” – five to ten minute presentations modeled after the popular “Ted Talks” – a chance for the speaker to present just one idea. This is a great idea – the best meetings are ones where you can learn from the other attendees as much as from the presenters. This gives people the chance to figure out who is in the audience next to them.


these ladies are wearing “paranda” – a traditional tassel or hair extension. I got a lot of these for the C.U.G.H. meeting last spring.I have some remaining and I’ll bring them. Want one? just ask!

The Three-Legged Stool of Global Health Nursing

That’s the title of my lightning talk. I needed to focus on just one idea, and that’s what I chose. It’s the most elegant way to think of how to advance nursing in Low Income Countries. Some projects succeed, some fail. Sometimes you see things that you want to change, and which can’t be changed no matter what you try to teach or do or model or support.

The three legs compose a “Schema” of interrelated phenomena. If you try to change one, without addressing the other two, your stool will not be level, and may collapse when you try to sit on it…….

First leg is culture and the role of women.


medical colleges in Nepal are working on “gender balance” but nursing is still female. The solidarity to be found in an all-female work group in Nepal is inspiring. There is an upside to go with the downside….

Second Leg is the nursing education curriculum and system.


seen on a classroom whiteboard of a PCL nursing school in Kathmandu, Nepal. Students there are regimented; they learn to love it, and even if they don’t it molds them a certain way…..

Third leg is the setup of nursing service. To understand nursing in a low income country, you must understand Functional Nursing – click here –

Study the above! ( don’t confuse it with the argument about “functional vs. dysfunctional,” that’s a whole ‘nother animal entirely).

got it?



some three-legged stools are fancier than others. Here is one with “patina” – age marks that make it beautiful.

How does it work? well, my best examples are from Nepal, of course since that is where I work.

The nursing service system is organized to provide “Functional Nursing” which is to say, task-based nursing. The hospitals are not staffed to provide individualistic nursing care such as we would think of with “primary nursing” or “team-based nursing.” Oh, individualized nursing care can happen, but it is on a  hit-or-miss basis.

The educational system (especially of the PCL level) teaches functional nursing. As long as the hospitals want and need functional nursing,  the PCL nurses will provide it.

Functional Nursing depends on the idea that nurses do what they are told and don’t generally ask questions. Functional Nursing is a way to get the mandatory tasks done with the least number of people – in that respect functional nursing is not good or bad, it is just  “is.”

which brings us to –

The role of women in the culture.  In Nepal, the traditional role in involves deferring to the judgment of males, or deferring to the doctor, or deferring to who ever is “senior.” In that respect, functional nursing is elegantly matched to the culture.

If you as a foreign colleague see an opportunity to “improve things,” you need to resist the urge to jump in and implement something in one of the three legs until you have assessed the impact on the other two legs. This schema can be used to assess whether a given intervention is “sustainable.”

That’s enough for ten minutes, don’t you think? If I were to exhaust the topic, I could roll it on into about eight hours of presentation.


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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