Global Health Nursing & Midwifery
Q&A with global health nurse and author Joe Niemczura
Joe Niemczura is an experienced RN and nursing professor at the University of Hawaii. He writes and speaks about his experiences volunteering at a small hospital in Nepal. After meeting him and reading his book, The Hospital at the End of the World, GHDonline posed a few questions to the global health nurse. Any additional questions may be posed directly to Joe through GHDonline, as he is also a member.
Q: As an experienced nurse in the US, how did you prepare yourself for working in a low-resource setting?
Joe: I took seven months of language lessons, and read every book on Nepal I could get my hands on, especially those which dealt with culture and customs. I studied Buddhism and Hinduism. In a stroke of luck, a person who had served in the place where I was going, came to Honolulu and I spent two hours with her talking about it one-to-one. I bought the CDC book on international medicine (not very helpful) and Where There is no Doctor (good but not quite applicable to my situation).
Q: What are some of the differences you noticed between the training/education of nursing students in the US as compared to Nepal?
Joe: First and foremost, in South Asia they still rely heavily on Nightingale’s methods of nurse education: using students to staff the hospitals; following a functional nursing model; relying on discipline and order. This has some good points – for example, when there are so many patients and so few nurses, you really do need to keep track of the basics such as who is in which bed and whether the lab tests actually get ordered, results getting collected and put on the chart. The flip side is, students are younger and not encouraged to do critical thinking especially in the area of “failure to rescue” and all that this entails. If the patient deteriorates, it is hard to muster the bedside resources to concentrate on turning the situation around. Next, there is a severe lack of trained faculty and textbooks. Often the nurse supervising the students is only a year or two older than the ones they supervise, and lacks the experience to teach in any other way beyond how they themselves were taught. There are also cultural factors at play, such as a tendency to over-respect the doctors.
Q: What medical technology was most valuable to you as a nurse in a low-resource setting?
Joe: Trick question, that! The most valuable things were my previous experience in the seventies working in a place that did functional nursing, and I suppose the summer I spent working in a nursing home. Why, because these teach you the value of using assessment skills and setting priorities when there is a large number of patients. Technology is a crutch, and clinical assessment is the key; what you can observe with your inspection, percussion, palpation and in addition to history taking and knowledge of the disease processes. The most consistent value I added was to model problem-solving and initiative.
Q: You wrote considerably about your experience with pediatric burn care in Nepal. Please elaborate on how to effectively treat burns in a low-resource setting.
Joe: Nutrition is key, using the diet available locally. At least one boiled egg per day! Also daily weights and enlisting the family support. Don’t be fooled to think that I felt as though my experience was a success. My exposure to burn care was a chance to deal with the limitations head-on. The best cure is prevention, and this will include a change in attitudes about the role of women in Nepal society.
Q: How are nurses regarded by both physicians and patients at the hospital where you worked? For example, are they considered to be an integral part of the healthcare team and able to significantly contribute to plans of care/decisions, or are they more often seen as ancillary/support staff? In otherwords, how would you describe the professional role of nurses in Nepal?
Joe: This is related to the use of functional nursing. The charge nurses or “didi” was always critical to the operation of the ward, and there are some in-charge nurses who function at a level of intellect that would serve them well in a similar role in USA. Right now so many of the nurses are young and still finding their own way as professional people. The role has been elevated in a curious way by the myths surrounding those nurses who work abroad and send remittance (money) home to their families. The curriculum is standardized by a national agency (CVEVT) and the younger ones are getting more community health experience which broadens their focus beyond the hospital. I think it is still evolving.
Q: In your book, it seemed there were many more physicians volunteering than nurses during your time in Nepal. Why do you think there were few nurse volunteers? How do you see the role of nurses, as distinct from other health care providers, in the field of global health?
Joe: What I did was to conduct bedside teaching in an inpatient hospital setting, a rarity for foreign nurses. It’s more often that a short term volunteer will function in a primary care role, which does not take so much preparation. There are few academics who have the confidence and background to take on a teaching role in this setting. Many elements need to be juggled and it is not easy. It’s actually easier to be a visiting surgeon than it is to do what I did. A nurse faculty has to have broad experience and judgment, weighing the organization’s readiness for change, the needs of the people, and other seemingly abstract elements. By contrast, a surgeon for example, can operate without having had a prior conversation with his patient. I think USA nurses need to learn and respect the ways that local conditions dictate the choices made by the planners of care, and that it is difficult to put this perspective into practice. The role of nurses as opposed to other health care providers, is to be as culturally competent as possible, and draw from a wide palette of sources for solutions to the problems of low resource. Cultural imperialism is something to which we all fall prey, and nurses can hold others accountable for their sensitivity or lack thereof.
Q: What was most difficult and what was most helpful with regards to your reintegration back to the US from Nepal?
Joe: I totally underestimated cultural re-entry shock, and I would advise that everyone plan for this from the beginning. There are excellent resources out there. My trip was a solo adventure and I did not have the support system in place until after I was dealing with my re-entry issues.
smita sharma
Firstly I really appreciate your helping hand for Nepali people
Q: In your point of view what is the most important elements that Nurses in Nepal should lead for healthy work environment and patient satisfaction?
9:05 PM, 4 Oct 2010 | Permalink
Joe Niemczura, RN, MS
thank you. the health system ther eis woefully underfunded, and relies of functional nursing model. The lack of money forces them to do it the way they do. You asked two questions - the first was about a healthy work envirnment. for this they need better equipment such as personal protective equipment. the second was about patient satisfaction. This latter issue is more complicated; for the most part, the population in the rural areas is not very sophisticated or knowledgeable so they are grateful for whatever they receive. It's hard to measure satisfaction! as the political parties get involved in advocating for patients, this has created an unforeseen difficulty, the political parties tend to create an adversarial relationship where none ought to exist.
6:22 PM, 6 Oct 2010 | Permalink