Exemplar
A story from the field - Kathmandu, Nepal
Colleen Rolls
School of Nursing and Midwifery, Australian Catholic University, Fitzroy VIC
PP: 117 - 119
Article Text
During 1994 I was the recipient of a Rotary grant entitled 'University Teacher to Serve in a Developing Country Award'. This enabled me to spend five months teaching at the Nursing Campus of Tribhuvan University Institute of Medicine, Kathmandu, Nepal in 1995.
Nepal is a very poor country with a rich cultural history. It is a sovereign independent kingdom consisting of many different ethnic groups. A large proportion of the population of 18 million people live in villages disadvantaged by distance and terrain. Hinduism and Buddhism constitute the two major religions of Nepal. Many travel writers describe Nepal as the land of temples as religion plays a significant part in the lives of the Nepalese people. It is also the land of the Himalayas that have been a magnet for mountaineers, adventurers and travellers since Nepal was open to foreigners in the 1950s.
Nepal has all the health care problems of a developing country including poverty, illiteracy, lack of health care facilities and insufficient health care workers. This is coupled with a culture in which women marry young and have a high fertility rate because of the desire to have male children. Life expectancy for females is fifty years and for males it is fifty-two years. Infant mortality is 128 deaths per 1000 live births.
Nurse education in Nepal
The first school of nursing commenced in Nepal in 1956. Since 1980, nursing education has expanded but only 2160 nurses have completed the three-year certificate in nursing at this stage due to the scarcity of primary and secondary education in Nepal until recently. In 1987, a primary health care oriented national nursing curriculum leading to a Certificate in Nursing was commenced at the seven nursing campuses, three of which are situated in Kathmandu. Student numbers are determined by nursing work-force requirements and there was a national intake of 280 students in 1995.
The three campuses at Kathmandu are affiliated with Tribhuvan University Institute of Medicine. Only one campus in Nepal, 'Maharjgunj' offers a two-year post-basic Bachelor of Nursing Degree which is for students who already have a Certificate in Nursing and two years clinical practice. There are currently sixty-three students undertaking that program. In addition, the Maharjgunj campus offers a Masters of Nursing in Women's Health and Development in which there are four students currently enrolled. There are no nursing speciality courses in Nepal. Nurses who work in speciality areas may receive some education in their field by obtaining work experience in an overseas country such as Japan. Japanese aid programs are very supportive of health care in Nepal and provide some education for Nepalese health professionals in Japanese hospitals.
Visiting Maharjgunj
The following is a description of my observations of an unfamiliar nursing culture during my orientation period as a visiting nurse lecturer at the Nursing Campus, Maharjgunj. The orientation program included visiting a government hospital in Kathmandu and a village health-post (community health centre). The hospital described is the oldest hospital in Nepal and is one of three generalist hospitals in Kathmandu. It is centrally located and resembles a Western hospital in appearance.
My first visit to the hospital was one of the most horrifying experiences of my life. It was crowded, dirty and smelt like pus and stale urine. Patients were accommodated in wards and corridors-in any space that was available. It was dark as many lights didn't work and only minimal equipment was evident. Despite that, the hospital has many areas of speciality including haemodialysis, peritoneal dialysis, neurosurgery, burns, trauma, disaster ward, and accident and emergency. The hospital accommodates 400 patients in mostly free beds although private cabins (wards) and private care is available. A six-month old baby with hydrocephalus was in the neurosurgery ward. He was nursed on an adult bed without cot-sides. The bed was against the wall and the baby was positioned in the corner. The nurses told me that he smiled and gurgled. He had setting-sun eyes and when I asked about a ventriculo-peritoneal shunt, I was told that he was waiting to have one inserted. The baby was flat with no animation on his face and he was swaddled so that it was not possible to see if he was well-nourished. The colleague who took me on the visit made me move quickly through the hospital. I think she sensed my horror. We visited the cardiac ward and saw a patient who had a recent valve replacement. She looked well.
The overcrowding, smell and hopeless appearance of the patients was reflected in the nursing staff who appeared disinterested. The disaster ward was full of patients from a mini-bus accident. Approximately ten people, both males and females had fractured legs. Despite the awfulness of the hospital, these patients had their fractures stabilised with modern surgical techniques.
Nurses employed in Nepalese hospitals work a variety of shifts each week including twelve-hour nights. They care for large numbers of people. In one neonatal intensive care ward, I came across one nurse and one doctor caring for twenty babies on an evening shift. This included a baby on a ventilator. The labour room at this same hospital has one nurse and a health assistant on night duty. Unqualified health workers, health assistants, nurses and doctors provide the medical care that is needed for patients. All other forms of care including hygiene and nutrition are provided by the family. A patient in a Nepalese hospital must be accompanied by two members of the family. One family member provides bedside care, the other brings food, collects medicine and does the washing.
Community health-post-Lele
Post-basic Bachelor of Nursing students are allocated to a health-post for a six-week community placement in the second year of their course. I accompanied Nepali faculty members to determine whether the health-post at Lele would be suitable for student placements. The health-post was in a village 15 kilometres from Kathmandu and consisted of three rooms where a health worker conducted clinics for sick villagers. It is often reported that the clinics at the health-posts do not occur because of lack of equipment and medical supplies and this certainly seemed to be the case at Lele. During my visit the only evidence of preventive health programs I saw, were some ageing health education posters on the walls.
Lele is close to Kathmandu but it took an hour to drive there because of the appalling condition of the road. The health-post was in an isolated position on a hill behind the village and was difficult to find. There were no people there when we arrived. It contained only furniture with no medical equipment or facilities for conducting a health clinic evident. After some time, a villager arrived to investigate our presence. Two students had been rostered to the health-post for their future community health placement and would sleep in a room upstairs for the 6 weeks. During the placement, students are unable to go home unless they get permission from the Campus Chief. The meagre facilities at the health-post consisted of a water hose outside, latrine a short distance away, traditional clay cooking facilities and no electricity, although there were plans to connect it in the future. The two students allocated to the placement accompanied us on this visit and looked very distressed at their future living conditions. The faculty reported that it was rustic but would be adequate and on the following Monday, the students were driven to their isolated and poorly equipped community placement in the campus bus.
Conclusion
This is a very brief example of my observations of nursing in Nepal during my orientation period at the Nursing Campus. The culture of nursing and the role of the nurse are so different from those with which I am familiar. Being in an alien nursing culture was both exhausting and confusing. On reflection, I now believe that despite the many differences in health care facilities and health care education in developing and developed countries, the Nepalese health system is attempting to address the country's problems. This is occurring through the education of nurses who are able to provide care for communities. Financial resources to address the scarcity of equipment and facilities in health-posts does, however, require attention.
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