Nursing Education in Bangladesh
Empowering Students in the Clinical Setting
- Alex Berland
Empowering Students in the Clinical Setting
While serving as an international volunteer at a nursing college in Dhaka Bangladesh, I taught medical-surgical nursing to some twenty relatively junior students. We had difficulty finding good hospitals for clinical practice, so we were using a small private hospital where at least the management was trying to do a better job.
“I would like to give the nurses more training,” said the hospital owner, “But as soon as they gain a little more skill, they quit my hospital and go to work somewhere else for a tiny bit more money.” It’s not hard to see where this conversation would lead, especially since most of the “nurses” working there were women in white coats who had almost no nurse education. Even where hospitals did hire qualified nurses, the quality of practice was often so poor that doctors did not even trust the nurses to take vital signs properly. All the same, we did our best to work with the friendly administration at this hospital to try to make things a bit better for patients through the supervised care by our students.
Towards the end of the course, the students experienced a very upsetting situation during their hospital practice. Most of the doctors working there had busy private practices outside and spent little time in the hospital. One physician decided that an elderly male patient was not responding to treatment and he told the staff to send the man home to die. The staff put the patient on a bare gurney, which they wheeled into a dark corridor, where they left him for several hours completely unattended before relatives could be notified and make preparations to take him home. Two of our students working on that ward saw the situation but could do little about it.
Understandably, all our students were terribly upset by this inhumane treatment, which we discussed in our “debriefing” session at the end of the day. (That was also the first time I heard about the problem.) When we all arrived for class the next morning, they were still very upset and angry, so I abandoned my planned lecture. We spent the entire class discussing what was wrong, what could have been done differently and, most importantly, what they could do to prevent similar situations. This was an opportunity to discuss assessment and the stages of dying, nursing management of physical symptoms and respectful care of patient and family at the end of life.
The ethical situation led to the students’ anger at the callous treatment by the staff and their own feelings of powerlessness and distress. They debated potential responses, finally deciding to write a letter to the hospital administration describing what had occurred and how dying patients could be better cared for. My role was to help them write the letter in a professional way so that it would be seen as constructive. I was worried that this might compromise our practice arrangements, which – although poor - were still better than nothing. Fortunately, the hospital owner was open to the feedback.
These situations and others like them were commonplace. We had developed our curriculum based on “international practice” as described in evidence-based textbooks. As we discovered, however, the most powerful learning opportunities sometimes developed from the worst clinical situations. Teaching student nurses “soft skills” is an essential part of forming professional identity and developing resilience without losing compassion. From this experience, we created in all our courses critical thinking exercises based on realistic scenarios about patient care that required not only technical knowledge but also ethical reasoning and communication skills.
Alex Berland September 12, 2019
What NI Means To Me
Kathleen Capone MS RN CNE
I’ve been working with Nurses International for about three years now. After working in clinical nursing for almost 50 years and Education for the better part of two decades, I am both amazed grateful for the opportunity to work with Nurses International. It is a full circle experience for me. Having cared for patients and then helped educate student nurses for most of my career, the idea of working just for the fun and enjoyment of it became a reality when I began to work with Nurses International. Having the opportunity to work in a faith-based organization where seeking God’s will and assistance in communal prayer is part of every project at NI, and it is such a blessing! I have had the opportunity to work with the kindest and most talented individuals who have also become great friends in Christ. NI Is a place where each person’s talents and ideas are welcomed as part of a valued contribution that achieves great results together. I have had the opportunity to participate in course development, curriculum design, faculty development, policy and procedural development, nursing conferences, professional and spiritual retreats, peer reviewed journal writing, and missionary work. These activities have been personally enjoyable and professionally satisfying to me as they give meaning to work that supports nurses around the world with the ultimate goal of sharing the love of Christ with all that we meet.
Elizabeth Benson is a nurse educator who saw a big problem. Students were being asked to practice IV insertion on a static mannikin verses a dynamic patient. IV arms are expensive and high fidelity simulations even more so. Elizabeth wants to ensure that every nurse has the tools, information, and skills she needs to provide excellent patient care.
She knew it was for something new, so she created a wearable simulation solution that is affordable, long-lasting, and usable in any environment. She has donated wearable simulation products to Nurses International to use in low income countries, and she's working hard to find new ways to educate nurses and healthcare workers regardless of their ability to access an expensive simulation center. We're so glad to have her on our team as an innovator, content creator, and leader! Thank you, Elizabeth for all that you do! Check out our IV Access page to learn all about IVs.
The Power of Narrative
Janet Shiffer, MSN, FNP-BC
Language is what separates humans from the rest of our planet’s animal species. To formulate and communicate using words gave birth to the phenomenon of story. Stories have the power to evoke imagery, emotions, rekindle memory, and inspire. Stories do much more than entertain, they also teach and enlighten the recipient, that is so long as the recipient is open and willing to hear and understand the story being told.
How many times have a group of people listened simultaneously to the same story and have walked away with a completely different interpretation of what was heard? I recall with delight a children’s game called “telephone” where a message is repeatedly whispered from person to person. The last person would have to say out loud what was whispered. This usually resulted in uproarious laughter because the final outcome was completely different from what was originally said. The power of the narrative and it’s appropriate interpretation is crucial in the arena of health care. The misinterpretation of patient history can produce unexpected and at times tragic outcomes. Poor history taking can lead to an incomplete assessment or inaccurate diagnosis and clinical plan. Nurses are keen observers and by far, very proficient in using the power of narrative in advocacy and assessment of their patients. However, personal/cultural bias, be it conscious or unconscious, time and resource constraints can obscure the interpretation of the narrative and lead to taking the incorrect clinical pathway. Despite best intentions, all nurses at times have found themselves guilty of this.
I had the amazing privilege of being a nurse practitioner working for the US Peace Corps in support of medical personnel stationed abroad, often located in very remote parts the world. The majority of my tasks involved the triage and consultation of incoming calls about Peace Corps volunteers who were seriously ill or injured. It was my job to find ways to best treat the PCV in their host country or to Medevac them out for more advanced care. I worked with an amazing team of foreign nurses and doctors with varying degrees of medical/clinical training who were doing their very best with what resources were available. English was not the first language for many of these clinicians, making the challenge of getting the right context of the narrative that much more important. Working across cultures, being cognizant of nuances and contrasts in meaning and intent was key. Listening was key. The ability to listen and clarify paramount.
So here are two funny stories told to me during my PC tenure.
Story #1 One of my colleagues was heading up a clean drinking water project amongst a nomadic people in the sub Saharan desert. These were an ancient people traveling in small bands moving from place to place with all of their worldly possessions. One of their dietary staples were flying locusts that conveniently flew into their mouths, sacrificially offering themselves up as a daily protein snack. Access to water was a constant issue for this population who were very adept in finding it, albeit not always the healthiest source. It was the mission of my very altruistic and well meaning colleague to develop a portable filtration system allowing for the consumption of cleaner, safer water. After almost 2 years of very hard work, the unveiling and presentation of this new system was at hand. When the day arrived, my colleague turned murky brown water crystal clear and prepared samples for the nomads to try. Much to her dismay, this “miraculous” transformation was was met with puzzlement and horror on the faces of her project recipients. Most of the nomads outright refused to drink the “purified” liquid, while some politely sipped then immediately spat it out, others exclaimed their skepticism. To paraphrase: “How could this be water? It has no color, no taste, no smell!” Much to the disappointment of all parties involved, this 2 year project simultaneously succeeded and failed. It succeeded in providing a working filtration system, but failed miserably in never being adopted and implemented by those intended to use it.
Another clean water project: This time, in a poor village where preventing diarrheal illness from contaminated water was the end goal. The daily task of walking several miles every morning to collect heavy vessels of water for drinking, cooking, cleaning and bathing was often the chore for women or girls. To the outsider, alleviating one of many arduous tasks women perform would seem a noble and beneficent act. To reduce morbidity/mortality from diarrheal illness: a
disease prevention victory. A water pump was installed within the village compound making clean water conveniently accessible and reduced the incidence of water borne diarrheal illness. However, it appeared that no one asked the primary stakeholders, the women, what they thought of this project. Their story, their narrative had been omitted from the process. Compliance in using this new convenience was resented by the women. When the women were finally asked why they were not pleased with their new “appliance”, they disclosed that one of their most treasured rituals had been taken from them: The daily opportunity to gather in the quiet of each morning with their fellow women; to walk together and share openly with each other out of the earshot of the men who controlled so much of their existence. For these women, although the task of fetching water was difficult, the reward of forging deep connections meant more. To be certain, none of these women wanted the continued suffering of their fellow villagers from illness, but the location of this pump was a major intrusion.
The nursing process is the gold standard for nursing scientific method …….the importance to assess, plan, implement or intervene, then evaluate is a dynamic process, which takes into account the whole person as part of a biopsychosocial system that is ever changing. Nurses have led the way towards what we now refer to as evidence based practice. It was Florence Nightingale that demonstrated how hand washing was key to reducing infections.
Listening to the right stakeholders, learning so as to forge the most effective and beneficial clinical interventions for specific, mutual clinical outcomes yields high probability that the outcome will be long lasting. It ensures that precious resources are not redundantly utilized to solve the same issue. The NI motto of listen, learn, serve and share encompasses the successful harnessing of narrative-
that uniquely powerful gift of language. The gift of the human story.
Janet Shiffer is a Family nurse practitioner. Her 40 year career as RN and FNP has taken her across the globe. She has witnessed and personally experienced the power of narrative in her own life. A victim of distracted drivers she sustained traumatic brain injury. Journaling and the power of story has been a major path to recovery for her. You can check out her personal blog: journeythroughthefog.com Prior to her injury, Janet worked as an associate research investigator of patient participants from all around the world with rare genetic metabolic/mitochondrial disorders. Her passion lies in global population health promotion/prevention, writing, reading, the arts, gardening…Oh and yes, March Madness Basketball, rugby and GrecoRoman Wresting, Track and Field, Tennis….OK, most sports.
Creating a Resource for the World
Jackie Christianson, MSN, FNP-C
My name is Jackie. I've been working as a Nurses International faculty member for three years. Nurses International gives me the opportunity to do something that matters on a global scale. I created an EKG manual that I hope will be used to train nurses and doctors and save lives.
I engage in content creation with Nurses International because I feel it is a moral imperative to use my skills to improve the lives of others. I am not personally religious or spiritually inclined (and feel religion has a negative net impact on society's well being) but I choose to work with some groups that are faith-based not because of their religious affiliation but because of their commitment to bettering the lives of others.
I chose Nurses International because of its dedication to expanding access to nursing education. I've made friends here, and I'm doing work that I hope will make a difference.