I served my elective nursing placement through Work the World in Pokhara, Nepal for 6 weeks. Given the fact that Nepal has a GDP of $1,200 per capita in comparison to $35,100 per capita in the UK, the budget for healthcare in the former is significantly smaller than the UK’s, resulting in a considerably different methodology of healthcare delivery. During that period I worked in the Emergency Department and Surgical Department of the Western Regional Hospital and worked in the health post at Nalma Village in Lamjung. While the following advice was developed from my Nepali experiences, they can be adapted towards nursing in the developing world.
Understand the local culture
Family dynamics within any culture tend to be reflected in the attitude of patients towards the healthcare professionals and vice-versa. Hence, the attitude of independence prevalent in British society is reflected in the rising number of informed patients wanting to have greater say in their healthcare delivery.
In contrast, Nepal has a patriarchal society, with the adult male being recognised as the head of the household. This was reflected in the deference of patients towards the treatment and advice given by the health professionals, and deference of primarily female nurses towards the male-dominated doctors over treatment options. This led to potential conflicts between the nursing students and the Nepali medical interns, particularly as many of the latter had undergone a training which emphasised on the theoretical knowledge of medicine without much practical experience, leading to less-developed skills in practical areas such as IV line management, reflected in their failure to check the lines for air bubbles before inserting them into the patient. Upon discussion with the other nurses, we found that the best way to successfully collaborate with the interns was by volunteering to perform these activities, such as setting up the IV drips to ensure that the air bubbles were cleared and ECG chest leads to ensure that they were placed correctly. Hence, while we had to adopt a deferential stance towards the medical staff, we ensured that we did not compromise on our professional responsibilities as student nurses to act in the patient’s interests wherever possible without causing conflict.
Pack your own Personal Protective Equipment (PPEs)
In the chaotic environment of the Emergency Department and even in theatre, blood spillage was a common occurrence, as patients often jerked their arms during cannulation. While staff have access to sterile latex gloves, these are washed and cleaned after use for repackaging, filled with talcum powder. Another point of concern was that if the user was allergic to latex, there were no alternatives available that we could find locally. Apart from the gloves, there are no other forms of PPE available apart from sterile scrubs for theatre. Eye protection was non-existent, as surgeons and scrub nurses had to use their own goggles in theatre.
Hence, it would be beneficial to bring along a box of disposable gloves and aprons to protect yourself against blood and fluid spillage. While I was able to purchase disposable gloves from the hospital pharmacy, I lacked aprons to protect my body from blood spillages and did get blood spillage on my trousers during one of my shifts in Emergency.
One of the first things that the staff asked me at each department upon learning that I would only be for less than a month was if I wanted to observe or ‘do stuff’, ie learning how to adapt the techniques I learned in the UK into the Nepali context. I opted for the latter and gained a wealth of knowledge from the nursing and medical staff on the means of improvisation and adaptation they have done, delivering the best form of care they can deliver despite the limited resources. As Gendaki is a teaching hospital, the staff are used to handling a deluge of student nurses. While many of them are highly capable and knowledgeable, most are not willing to step in and volunteer and assist unless asked to. Hence, the staff were happy to have proactive students willing to learn as much as possible, enthusiastically showing us the types of dressings they use and the adaptations they have done, such as using IV lines as tourniquets in the absence of actual tourniquets.
Hence, don’t be afraid to jump in and assist wherever possible within the best of your ability. While no-one wants become ‘just another pair of hands’, the learning you will gain through the hands-on experience, such as the methods of differentiating between venomous and non-venomous snake bites and triaging casualties is extensive and colourful, to say the least.
Scrubs vs uniform
Most of us working in the hospitals preferred the use of scrubs to our normal nursing uniforms, as they could be easily disposed of if stained in blood or fluid spillages. While some did opt to wear their nursing uniforms instead, I would personally recommend scrubs as they would be more comfortable working in the warmer climate.
While the donning of the white coats was a must in the hospitals, the relaxed uniform discretion in Nalma meant that the medical student and I were able to work without them in the village, reducing the weight of our rucksacks. In addition, a large number of short-sleeved coats were available in the Work the World house, which were much more comfortable than the long-sleeved coats available in the UK as the latter were designed for a temperate climate. Hence, it might be beneficial to utilise the coats in the house instead of procuring one for use overseas.
Nursing in the developing world demands a great level of confidence and adaptability, integrating the techniques we learnt in university into practice within the local context. While it might seem like a daunting task, it is easily achievable and I would highly recommend it to anyone interested in working in the international field in the future.
Written by George Glass, nursing student at the University of Edinburgh.