Rhonda Martin MPH, BSN, RN

Nepal is a land of contrast personified by the warmth of its people, but punctuated by decades of violence. The Shangri-La of the high Himalayas adorns the northern border with Tibet, and a jungle full of tigers, rhinos, elephants and crocodiles traverses the country’s southern border with India.

The capital, Kathmandu, is a teeming polluted city of a million folks, including refugees from the rural areas where Maoist violence forced them to leave. It is at once Hindu and hippie, Buddhist and business hub, temple-filled and touristy. Sacred cows make themselves at home on busy streets causing ever greater traffic jams. Monkeys inhabit the temples and surrounding environs, stealing anything that isn’t guarded. Monkey crime is serious business in Kathmandu.

Nepal is an exceedingly poor country hampered by a decade-long Maoist insurgency that claimed 13,000 lives. The insurgency obstructed the delivery of basic services and caused a breakdown in family and community networks. The adult literacy rate is 57 percent, and life expectancy at birth is 67 years. The infant mortality rate is 41 per 1,000, but that is down from 99 per 1,000 in 1990. Two thirds of Nepalis are still without toilets, and 15 percent of Nepal’s wells are contaminated with arsenic. There is no clean water in Nepal.

As you would expect, there are a lot of infectious diseases present, notably typhoid fever, tuberculosis and hepatitis E. But in the cities, there has been an exponential increase in the so-called “western diseases” such as stroke, diabetes, hypertension and myocardial infarction.

In Kathmandu, a charity hospital called Patan Hospital was opened in 1982 by Christian missionaries and has grown steadily since. The medical staff is mostly western educated and work at a high degree of professionalism and expertise. The staff is a committed group who want to see the hospital advance.

Brain drain is a serious problem in Nepal, as it is in all developing countries. Some of the doctors have begun an organization called the Patan Academy of Sciences, which is dedicated to training doctors from the rural areas. The goal is to have them go back to serve in their communities. Their education is free, being paid for by the government and charity funds. Teaching is accomplished through volunteer expatriate professors.

During the summer of 2008, several doctors from Patan Hospital came to Harvard Medical School and BWH to recruit doctors to teach at the Academy. An ancillary goal was to improve the caliber of care in the hospital in general and the ICU specifically. This could not be accomplished without dramatically improving the education and training of the nurses. Knowing some of these doctors from previous visits, I got the call to join them for discussions on whether it would be feasible to launch a program for their nurses using BWH nurses as teachers and mentors.

As the discussions proceeded, I found that the goals of their proposed program matched my global health philosophy and values. Over the years I had participated in many global health missions and observed many others. I was becoming increasingly discouraged and jaded by the lack of sustainable accomplishments or tangible outcomes after years of involvement and millions of dollars spent on a project or community. Most short-term missions seemed to serve the needs of the volunteers, not those of the locals. It was about feeling good about yourself, having a great cultural experience and having an impressive entry on your resume.

This view is reflected by professionals in the field and informs the philosophy I developed. My philosophy is based on four principles:

I need to be invited by the people with whom I will work. They must have concrete definable goals. I need to be on board with their goals, not my own, and confident that I could deliver on those goals.

The focus should be on teaching and mentoring, allowing the locals to do their own work and take responsibility for their own progress. I would provide outcomes data related to the stated goals.

Coordination and cooperation with other NGOs and groups working with the same people or same projects is imperative in order to reduce needless duplication of services and supplies or omission of services and supplies.

I need to feel passionate about the people, culture and geographic location in which I am to serve if the program is going to be long-term and sustainable.

With this philosophy in mind, I headed to Kathmandu for an exploratory visit. Being invited by the doctors was not sufficient. I needed to hear from the nurses themselves that they wanted us to provide this program. I spent two weeks alongside the nurses in the ICU, met with the nurses individually to ascertain what they felt they needed to learn, had discussions with nursing administration and hammered out concrete goals as articulated by them. The beginning goal was to increase the knowledge and practice skills of the ICU nurses (25 of them) in the area of cardiac nursing.

In March of 2010, the first step in our journey began as Jeanne Praetsch, MS, RN, CCRN, and I set out for a two-week mission to Patan hospital to teach and mentor the ICU nurses in cardiac care. Jeanne took the lead in developing the program, adjusting it daily to the nurses needs, and evaluating the outcomes.

Jeanne Praetsch and Rhonda Martin enjoy a final tea with the staff of Patan Hospital.

Jeanne E. Praetsch, MS, RN, CCRN

I have always been interested in reading and listening to accounts of my colleagues’ participation in projects or work in developing countries. When Rhonda asked if I would be interested in joining her on a trip to Katmandu, Nepal, to participate in an educational program targeted for the ICU nurses of Patan Hospital, I was excited but a little intimidated. I could not imagine how to overcome the barriers of language, culture and limited resources.

I wondered about their educational and experiential knowledge and about their current critical care practice environment. Over a period of four months, Rhonda contacted the nursing leadership and physicians she’d previously established relationships with to ascertain some of the information necessary to construct our educational program.

Then began months of preparations to accumulate enough content to cover the range of information they requested: Cardiac A & P, BLS, ACLS and information on the care of the critically ill cardiac patient. Patan Hospital is a charitable hospital which cares for the most impoverished people of the city. There are minimal, if any, funds to support interventional labs. Therefore, first-line treatment for the patient experiencing an Acute MI is thrombolytic therapy and/or medical management. They do not have the ability to monitor hemodynamics with pulmonary or arterial lines, so they rely on their physical assessment skills for care of their post-MI patients. I developed presentations specific to the nursing assessment of the AMI patient and utilized current nursing research and AHA guidelines for development of content for nursing care of the MI patient.

Rhonda and I arrived in Kathmandu—donated infant mannequin and CPR mannequin chest tucked under our arms—excited to meet the nurses of Patan Hospital.

I was relieved to find a very welcoming and enthusiastic staff and leadership. They quickly arranged for the staff to rotate and attend education sessions before and after their shifts or on their days off. The nurses were not paid, nor did they receive any form of compensation. However, they were all excited to attend as they do not have any formal training to work in the ICU and many of them had been there for a few months.

Rhonda and I worked for six days starting on Sunday (the first day of their regular work week) from 7:30 a.m. to 4 p.m. in the hospital. I provided two three-hour sessions each day, repeating content in the afternoon for a second 10-person group. Nurses from the ICU, telemetry unit, ED and high risk maternity unit attended these classes.

I worked to revise my presentations each night in order to meet the observed and identified needs of the staff from that day’s class. I was particularly challenged by the unavailability of electricity between 7 p.m. and 6 a.m. every night and only the prayer of a computer battery life long enough to prepare in time for the next day! There were no “Kinkos” or other copy centers to copy the rhythm strips or documents. Therefore, what we brought would need to suffice. I occasionally utilized their very dated (sometimes working) copy machine, although fully aware that I was using ink that they could not afford to replace.

The nurses really enjoyed the “hands-on” that BLS mannequin practice provided and also thoroughly enjoyed dysrhythmia interpretation. There was so much laughter, but so many serious clinical questions about how to best care for their patients. They reviewed the strips in class, took practice strips home and then came back the next day to see if they’d been “correct” in their interpretations. They did report frustration that they did not have electricity the night before, or had to work all night, and therefore did not get to practice.

The nurses of Kathmandu are friendly and receptive to any information we bring them. The physicians and leadership of Patan Hospital hope to develop a more multidisciplinary and collaborative health care team with nurses as active participants. They acknowledged the improved outcomes for patients and hoped for improved retention rates for the ICU nurses. The limitations of the nurses are many, but a few that I identified were that they recognized their limited resources and accepted that there is only so much that they can do with what they have available to them. There is a spark to learn when material is delivered to them, but an absence of self-motivation to read and utilize the medical library or electronic professional resources which have been provided.

One of our observations was that they do not have an expert critical care nurse to function as a mentor, modeling for them the assessment of their patients, the development of a nursing specific plan of care, or how to participate as a member of a multidisciplinary care team. They lack confidence because of their limited critical care knowledge and experience. However, the nurse manager and most solidly clinical expert of their staff, Shanta, stated “There is so much potential and hope in all of them, but after they get experience and learn what they can here, they leave to go to better hospitals or other countries because of the limited opportunities in Kathmandu.”

In October 2011, six BWH nurses will travel to Patan Hospital to teach ICU courses on nursing care of the cardiac, surgical and thoracic patient, ICU standards of care, nursing practice and quality improvement, as well as help lay the groundwork for the opening of a new School of Nursing through the Patan Academy of Sciences. The nurses are Catherine Saniuk, MSN, RN, Edward Arndt, NP, RN, Tess Panizales, MSN, RN, Jeanne Praetsch, MSN, RN, Sonia Thompson, MBA, RN, and Rhonda Martin, MPH, RN.

Jeanne Praetsch teaches CPR.