Special act of a nurse I

I was attending lady in labor, when suddenly another lady was rushed in with profuse bleeding PV and excruciating pain lower abdomen, accompanied by two small children. I instantly recognized this lady, she received four units of blood transfusion few days before. Vitals signs revealed that she was in shock and immediate management was initiated. She required another unit of blood and I told the children to call for donors. In the mean time I was attending the delivery case and few minutes later sister Tal came with a unit of blood in hand. I excitedly asked her, “Ena haruko donor ayo? “Ayai na!” she told, “Aanta koley deyo?” I asked, “Maro Bura bolayo nee” which means she called her husband and made him to donate blood to this lady in her care. This is how my colleagues are, very generous……

So with one unit transfused, the patient was stabilized and we could transfer to Gelephu Hospital. I am in doubt whether this patient and their children will ever remember this incident, but I would always remember this moment, the special act of a nurse…..

THOSE NURSES WITH HEART OF GOLD I

We all want to help the people in need but there are few people who actually come forward during the exact hour of need and they make lot of difference to the life of the patients. Every one of us is good nurse but there are some best ones among us Many a times I am forced to think twice and just appreciate, but I just feel guilty simply thanking them verbally and I know that it isn’t enough.. Besides helping the people in need they are such a lovely people to work with. It is worth telling to the world, their genuineness in their work, I will try to narrate about them with some significant incidences worth letting the people know. Perhaps, readers would join me in appreciating these colleagues of mine. At the moment I will just give a brief introduction………

She is my role model for how to stay fit, middle aged, smart lady in terms of look and act. She is our lovely sister Tal.

There is one among us; people call her Aum sister and fondly known to us Madam PRO. She is our mini telephone directory and our connection to people beyond hospital staff. Ready to help anyone and a multi-tasker, she is Sister Sonam Wangmo.

Young and junior to me, but more kind and skilled than me. She is the backbone of the nurses and also the ‘stand by’ of all the nurses. She is none other than Sister karma Tseten.

Brother Emal and brother Prem, smart they are but much smarter is their work. Most professional and efficient male nurses and the comfortable people to work with.

Brother P Wamgdi and sister S Pema, though much younger their conducts are very mature. As they grow up, I have no doubt our people will be in safe hands.

PS. (Individual incidences will follow……..)

EMOTIONAL INTELLENGENCE AND THE NURSING MANAGEMENT

I think I have garnered enough experiences as a practicing nurse to write it down and have some fun. Every profession has its high points, but nursing in particular teaches us what humility is all about. If we base our life on this single quality and approach any sort of situation with lowered expectation, definitely there is lesser chance of disappointment. Nursing to me is not only a profession to earn myself a living but my passion to learn and understand more about human beings and sometimes I don’t want to deny the few happy people’s comments as “Lungtengi Sister” (lol) but of course very rare comments……. Jokes aside! I am writing down my own understanding about the Emotional intelligence which is very important aspect and applicable in the field of Nursing. A quality that must be learnt and develop to understand one another better.

Emotional Intelligence is the capacity for recognizing feelings in ourselves and in others and managing them well. It is distinct from general intelligence (IQ) which reflects our cognitive (neuro-psychological capacity), which is correlated with pure academic intelligence.

Nursing is people centered activity and the profession happens in a strong emotional environment. Nurses are expected to show emotions that conveys caring, understanding, hope and affection even when they feel tired,bored, fearful, irritated or demoralized.

Emotional intelligence found to matter twice as much as IQ and technical skills put together in producing superior managerial job performance.

For newly graduated nurses, the transition from student to clinical nurse is challenging.

Emotionaly intelligent senior nurses like nurse managers, nursing superintendents and chief nurses can be of great help to them.

Essential skills for nurses are clinical skills, management skills and leadership skills.

Emotional intelligence is more intricately linked with management skills and leadership skills.

We can understand this with two dimensions

1. The ability to understand and manage oneself (self awareness and self management)

2. The ability to understand and relate well to others (social awareness and relationship management)

Frame work of emotional Intelligence

Self	others
Self –awareness	Social awareness
Self-Management	Relationship Management

Self awareness of the moment to moment and situation to situation variation in initial emotions.

Awareness of the reaction to internal and external stimuli.

Emotional intelligent persons are aware of their own feelings and understands them accurately.

They have the confidence to continue activities appropriately, inspire of their emotions.

Self-Management

Self control of emotions, Adapting to emerging situations, Contrasting profiles, Impulsive, short tempered, rigid, easily hassled, defensive, critical.

Calm, composed, tolerant, open-minded, flexible.

Social awareness

Directly related to the capacity for empathy

Empathy-the ability to sense others’ feelings, needs, concerns and perspectives

Having active interest in others

Relationship management

Inspiring and influencing others, Developing others, Leadership, visioning, Collaboration, teamwork and conflict management

Development of Emotional Intelligence

Both genetic inheritance and social influence (since childhood) contribute

Out-come of the interaction of the capacity plus the opportunities that help to develop that innate capacity to evolve further.

We can improve our Emotional Intelligence by developing our emotional competencies- the related skills. All emotional competencies can be learned and developed. The related competencies are personal competencies and social competencies.

1.Personal competencies are as follows:

Self awareness skill

Emotional self awareness, Accurate self assessment, Self confidence

Self-Management skill

Emotional self control, Transparency, Adaptability, Achievement, Initiative, Optimism

2.Social competencies are as follows:

Social awareness

Empathy, Organizational awareness, Service orientation

relationship Management

Developing others, Inspirational leadership, Change catalyst, Influence, Conflict management, Team work and collaboration.

Teaching and Learning in Nursing Practice (Clinical Practicum Analysis)

Introduction

Teaching is not the exclusive domain of academic institutions; there is pressure on the health professionals to satiate the ever-increasing demands of the patients and public for better and efficient services due to advancement in medical sciences which has made detection, diagnosis and treatment of diseases easier. Nurses play an important role in the education of fellow nurses and that of patients and public besides their own education. Increasingly, less doctors and nurses prescribe medicines in their consulting rooms to the submissive patients. Learning and teaching in nursing practices is an important activity that is being carried out on a regular basis; this requires them to update their knowledge and skills constantly. Evidence-based practices enable the health care professionals to explain or justify the procedures carried out in good faith.

Clinical teachings are conducted in most hospitals in Bhutan; it not only educates patients and their escorts but also enhances the learning and teaching techniques of the health professionals. The monthly clinical and mortality meetings provide good forums for teaching-learning activities. During these meetings, discussions take place on medical cases and ways to manage them effectively. Nurses make presentations on clinical topics and receive feed backs; they also conduct clinical presentations in the presence of the nursing superintendents.

This Paper is a descriptive analytical report on clinical teaching practicum conducted by the author. References are made to the relevant literature. The practicum was aimed at teaching mothers to manage children with diarrhea at home with the use of Oral Rehydration Salt (ORS), and to seek timely medical assistance when the ORS fails to produce the desired results. Observers (fellow nurses) used standard forms and formats to assess the presentation and provide feed backs (Annexure I). The outcome of the practicum is derived from the assessment made by the observers and author’s own evaluation of the performance of the participants. The practicum proves that given the right teaching strategies and techniques mothers could manage simple and common aliments at home.

Learners and Learning Needs

There are different theories on how the learners learn best based on their dominant perspectives, such as psychological theories, developmental theories and social theories (O’Corner, 2001). The learning need differs from group to group depending on their goals or objectives, which may change with time (Ray, 2004). According to Knowels (1980), it is the situation or circumstances which compel people, especially the adults, to learn; and the knowledge shared and perspectives formed by a group of learners become a source of new learning. In such a scenario, the educator simply facilitates learning rather than providing knowledge; the group learns itself.  Similarly, Friere, (cited in O’Corner 2001) states that “[l]earning is a collective process among individuals who, together, seek solutions to the everyday problem of life.”

Adult-learning or andragogy differs from children-learning or pedagogy (O’Corner, 2001). Children learn as a part of the overall development. Adults, on the other hand learn in order to fulfill specific needs like career advancement. This Paper, for instance is being written to update the knowledge of the author as well as for her career advancement. Similarly, conducting a practicum has a dual purpose. Firstly, it improves the teaching skill of the presenter. Secondly, it enhances the knowledge of the target audience.

The pre-assessment of the learners showed that most of the mothers did not know how to prepare the ORS correctly although most of them exhibited familiarity with it. There was confusion on the quantity of water required to dissolve the specific quantity of ORS.  They used bottles of varying capacities to dissolve arbitrary quantity of ORS. This was mainly due to inability or negligence of the mothers to read the capacities of the containers inscribed on them. Some mothers used either hot or cold water instead of boiled and cooled water. A few mothers fed ORS to their children in its original powdered form.

Clinical Practicum

Clinical teachings were conducted in the wards of Samtse District Hospital for the mothers who were caring children suffering from diarrhea towards partial fulfillment of the assignment. The number of participants varied from a minimum of three to maximum of five mothers in a group excluding the nursing collogues evaluating the author. The teaching sessions were conducted at five different times with different groups of mothers, each session lasting for about two hours. It was expected that at the end of the session, the mothers would be able to detect the signs and symptoms of dehydration and administer ORS to their children effectively; they were expected to be able to prepare oral rehydration solution correctly as well as decide when to seek medical help.

The session commenced with the pre-assessment of the knowledge of the mothers on diarrhea and its management, followed by the statement of the objectives of the sessions. Attempts were made to make the session as lively and informal as possible and keep learners interested and motivated through out the session; they were made to feel comfortable with minimum distraction. A baby patient was used as an example beginning with its condition at the time of admission. Gradually, the mothers were shown the signs and symptoms of dehydration – for instance, sunken fontanel, absence of tears when crying, dry mouth, slow retraction of the skin when pinched, the child is irritable and lethargic, etc.

The mothers were then shown how to prepare the ORS emphasizing on the cleanliness to be observed during the process. Irrespective of the nature and size of the containers - soft drink bottles, wine bottles and mineral water bottles, mothers were shown to prepare a packet of ORS in a liter of water. It was made sure that the water was boiled and cooled before dissolving the ORS in it. Every mother was given opportunity to prepare the ORS for acquiring first hand experience. This was followed by discussion during which errors committed during the preparation of the ORS were rectified. The session concluded with recapitulation of the lessons learnt during the session.   

Teaching Strategies

The importance of the choice of the teaching strategies can not be overemphasised as they have to be appropriate for learners in terms of their abilities, experience, and other characteristics (Reilly and Oermann, 1999). As stated by Heidgerken (1982), “lecture is a teaching procedure consisting of the clarification or the explanation of facts, principle or relationships which the teacher wishes to the class to understand.” However, as can be deduced from its definition, this teaching method, which is time-consuming, monotonous and involves fewer physical activities. It may suit the literate learners, not beginners, or illiterates, as is the case in this practicum.

Demonstration method is extensively used to teach nurses. It is also used in hospitals to teach patients and their relatives or escorts about procedures or treatments which they are required to carry out at home on their own (Heidgerken, 1982). This practicum was designed to meet the normative need of the mothers for the effective management of children with diarrhea (Bradshaw 1972, cited in Wass, 2000).   Since the learners were illiterate, ‘lecture-demonstration’ method was used consisting of short lectures punctuated by demonstrations with the help of audio-visual equipment. This method prevents monotony and formalism, and keeps the session simple and interactive. This teaching method was effective with these learners since the objective of the session was to improve the knowledge and develop the skills of the mothers for independent preparation of the ORS.  The medium of instruction was Nepali, the local dialect of the people of this part of the country. Each session was made as informal as possible in order to motivate the mothers to participate and get the maximum benefit from the session in terms of all three domains - “cognitive, psychomotor and affective” (Ray, 2004).   

As stated by Kirkpatrick, Weaver and Yeager (1998), strategies to evaluate the learners must be set up along with the aims and objectives of teaching-learning (p. 381). Similarly, learning has to be evaluated to determine whether the objectives have been achieved. In other words, teaching-learning process must include assessment of the needs of the learners, setting the objectives to be accomplished, selecting the strategies for teaching and, finally, confirm whether learners have achieved what the session intended. In this practicum, ‘impact evaluation’ method was used to assess the immediate outcome of the teaching (Ray, 2004); mothers were assessed through return demonstrations and verbal questioning.

Learning Outcomes

Evaluation is an ongoing activity at all stages of the session. There are mainly two methods to evaluate learning outcomes: The formative evaluation is conducted when the event to be evaluated is in progress; the summative evaluation is conducted at the end of the session (Kirkpatrick, Weaver and Yeager, 1998).  In the context of formative evaluation, for example, mothers’ attention to the lectures, readiness to learn and participate in return demonstration, eagerness and promptness to understand and answer questions led to the inference that the session was successful.  Summative evaluation was carried by verbal questioning technique which revealed that most of the mothers could understood signs of dehydration as well as remember the steps for preparation and administration of ORS.  This shows that the teaching strategies vis a vis the learners was correct and the outcome of the teaching fruitful. Some mothers were exceptionally quick learners considering their background and the length of the session.

Conclusion

Learning never ends; more so in the medical field. However, it would serve little purpose if the knowledge and skills are not disseminated.  Effective teaching requires use of appropriate strategies. Besides, the varied needs, backgrounds and circumstances of the learners must be taken into consideration. As this Paper shows, nursing practices demand analytical and problem-solving skills and involves continuous learning and teaching. However, nurses can not be an effective educator if they are not confident or well-informed. Besides, teaching is more than transferring knowledge from teachers to learners; teachers increasingly play only facilitative role. Further, the benefits and effectiveness of teaching must be assessed and feed back provided for improvement. After all, learning is not simply acquiring, retaining and applying knowledge; it must be useful to the learners and make them think critically and laterally.

Teaching and Learning in Nursing Practice (Health Education Plan)

Introduction

The concept of nurse practitioners or independent nurses is relatively new in Bhutan. As a result, currently, majority of the nurses simply wait for the doctors´ orders. Since nurses are in maximum contact with the patients they can play crucial role in the health education of the patients and public.

The International Council of Nurses’ code of ethics for nurses (cited in Nancy, 1984) states that the basic duties of the nurses are to: promote health, prevent illness, restore health and, alleviate suffering.  Accordingly, it is important to educate patients, such as, on how to live normally with the disease and to disseminate information to the communities on healthy habits. This makes it is very essential for the nurses to learn to design a formal health education plans and execute them professionally. A well-designed health education plan aids in disseminating accurate information to the learners; it prevents deviation from the main theme of the teaching.  In the absence of a written plan, a teacher risk missing out important information which might cost or save lives.

This Paper seeks to analyze health education plans (Plan) and design and execute one on dietary regimen for a patient who is recently diagnosed as a case of diabetes mellitus. The author used the format for the patient’s teaching plan which was developed by the Ramathibodi School of Nursing, Mahidol Unversity, Bangkok, Thailand (please see annexure I). The diabetic diet plan was designed at Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan. It is designed to suit Bhutanese patients considering their dietary habits and availability of food items (please see annexure II). This Plan takes into consideration the use of all three domains of learning: cognitive, affective and psychomotor (Ray, 2004). The session includes the patients and his wife since she has to assist the patient to cope with the changes in his diet.   

Knowledge Needs and Characteristics of Learners

There is little or no official data on the diabetic morbidity among the Bhutanese population. There fore, the Plan draws mainly drawn from author’s personal and hands-on experience during service in hospitals around the country. The path to ensuring the prescribed food to the patients according to their ailments is strewn with hurdles; different eating habits, socioeconomic status, lack of choice of foods and literacy of the patients are some of the challenges.  Critical analysis reveals that term ‘balanced diet’ lacks equivalent term in Bhutanese vocabulary, especially that of the general public. As a result, foods are mainly consumed for the purpose of satiating hunger more than to obtain vitamins and minerals for smooth function of the bodies. In other words, Bhutanese cuisines lack variety.

Initially, it was erroneously inferred that the reason why the diabetic patients’ were repeatedly hospitalized was solely due to their non-compliance with the medical regimen. However, a closer look at the problem revealed that there were misconceptions and myths about the dietary requirements of diabetic patients: some patients completely stopped consuming foods that grew under the soil; some patients ate only boiled rice; some ate only maize and locally produced corn flakes – thereby depriving their bodies of the essential minerals and vitamins. There fore, it was found that patients and their parties need to be educated on dietary aspect of the disease as much as on the medical aspect. In one incident, a known patient of diabetes was brought to hospital. She complained of giddiness, sweating and slurring of speech following an insulin injection. When she was given sugar she refused to eat it saying that she should not anything that tastes sweet. This could be interpreted to reflect poorly on the effectiveness of the health educations on a condition called hypoglycemia where the sugar in the blood falls below the normal level which is equally dangerous for the patient.

The need exhibited by the patient and his wife for this session is a normative need which is identified by nurses for the benefit of patient (Bradshaw 1972, cited in Wass, 2000). The needs are listed in the lesson plan according to their priorities.  This is expected to be covered in 30 minutes. (Please see annexure I)

Strategies

Grand plans would serve little purpose if they are not supported by appropriate strategies to execute them. However, Forbes and Prosser (cited in Forbes, 2004) are of the view that besides the strategies, the teachers’ perceptions and approaches are equally important. The success of the health education also depends on factors such as location, illness or fatigue, literacy, self efficacy, maturation and habituation of the learners (Forbes, 2004).  Accordingly, one-to-one instruction of experiential learning strategy is used to give the health education on diabetic diet (Fitzegerald, 2003). This is the most appropriate strategy for this session since the patient and his wife are in the state of pre-contemplation (Fitzegerald, 2003); they are aware that they need to learn about and live with the changes in the diet of the patient.

One-to-one instruction has many advantages over other teaching strategies; it gives sufficient time to understand the topic as well as build rapport between the teacher and the learner and, adjust the strategy in accordance with the learner’s pace of learning. This strategy also enables the educator to assess barriers for learning, for instance the level of motivation of the learners.

Conclusion

As the doctors’ are required to learn and teach besides diagnosing diseases, learning and teaching is also inherent in nursing profession. Teaching involves planning and knowing ways in which people could be taught effectively for successful learning outcomes. Plan involves formulating aims and objectives, and devising strategies to ensure proper learning environment while keeping the learners’ needs and evaluation in sharp focus throughout the entire phase of the implementation of the Plan.  This Plan dispelled many myths woven around the diabetes and dietary requirement of its patients; it aided the author in driving home of the message that ‘sugar disease’ (as the diabetes is known among the Bhutanese people) requires maintaining optimum level of sugar, not avoiding it altogether.  

Educative roles of Nurses in Bhutan

Introduction

As a Buddhist saying goes, “the merit gained by doing other good deeds can not be compared with the merits gained from helping a sick person”. Though such a merit is intangible and not acknowledged, success and sustainability of our society will be at stake without filial and mutual care of our siblings and fellow human beings, especially the sick and the dying. According to Nancy (1984), “[o]ur work today as a nurse is a continuation of the work done by our parents, since the beginning of time”.

The word ‘nursing’ comes from ‘nutricius,’ meaning, to nourish, cherish, protect, support, sustain, etc. It also connotes training, education, or supplying the essentials of growth and progress. Literature reveals that we are just beginning to appreciate or understand this wholesome meaning of nurse and nursing; it would be unfortunate if society continued to label nurses as ‘baby nurses’ or people who are ‘tender to sick and wounded’ (Daly, J., Speedy, S., and Jackson, D., 2000, p. 40).  Nurses have also been stereotyped as ‘angels with pretty face,’ ‘doctor’s hand maidens,’ ‘naughty nurses and nymphomaniacs’ (Daly, J., Speedy, S., & Jackson, D., 2000).

Though ‘old habits die hard,’ the image and status of the nurses and nursing profession seem to be improving beginning with the selfless sacrifices of pioneers like Florence Nightingale and others who followed in her footsteps at a time when nursing profession was not very respectable. Florence Nightingale attempted to place nursing profession at par other professions with its specific roles, responsibilities and goals; nurses not only nurse the sick and the wounded but are involved in teaching their colleagues, patients and members of the public. Continuing education of nurses is an integral policy.

This Paper highlights this indispensable role of nurses, i.e., the educative role, in Bhutanese context. It seeks to emphasize that nurses not only ‘nurse’, but play active roles in the education of patients and their relatives. Fellow nurses, consciously, or otherwise, learn a lot from each other at work place. Due to lack of relevant and authoritative Bhutanese literature on the subject matter, the Paper is based mostly based on the author’s personal experiences while serving in hospitals around the country.

Educative Roles of Nurses in Bhutan

Ever since the inception of modern health care system in Bhutan in the early 1960s, nurses were engaged in the comprehensive health promotion activities including information giving, encouraging behavior change, etc. Besides, due to shortage of doctors, nurses play crucial role in patient education. However, the effectiveness of nurses as educators depends on their motivation (remuneration and allowances), national policy and working atmosphere. In order to encourage the nurses to work harder, one of the senior nurses was awarded a prestigious medal by King Jigme Singye Wangchuck in 1999.  However, hard work and sacrifices of majority of nurses are yet to be acknowledged and rewarded. Positive feed back on nurses and nursing profession are few and far between. Voices of nurses often get drowned in the sounds of the sick and the dying.

Nurses undergo long and rigorous training at the Royal Institute of Health Sciences (RIHS). The Institute trains different categories of nurses, such as, General Nurse Midwives (GNMs), Assistant Nurses (ANs) and Auxiliary Nurse Midwives (ANMs). Though the training prepares the nurses to work at any level of health care setting and facilities – preventive, promotive or curative aspect, the ANMs are mainly trained to staff the Basic Health Unit (BHU) and to carry out the Primary Health Care (PHC) activities more intensively (Mehta, G., 2005). The GNMs and ANs are mainly trained to work in hospitals.  According to their official  job descriptions, 15% of the time of the GNMs and 10% that of  ANs’ is intended to be used for incidental teaching of patients, relatives, students and other staff. Some nurses are working independently in Health Information and Services Centers, while others are carrying out prevention and promotional activities under the Department of Public Health (see Annexures I and II).

Some nurses are given short-term trainings both within and outside the country.This enable them to obtain new skills required to be leaders and partners in health care and respond to the needs of people. In accordance with the decentralization policy, most of the development activities are carried out by the field staff, such as training of trainers (TOT), mass vaccination campaigns, etc., The author, for instance, was a co-facilitator in training BHU staff on reproductive health, comprehensive care of HIV/AIDS patients, new protocol of the treatment of sexually transmitted Infections (Annexure III) and management of severe malnutrition. The facilitators are trained by resource persons from the Ministry or by foreign experts. Such exercises improve teaching skills as well as cost effective as the trainings are replicated and relayed to the other hospitals and provinces.

Nurses working in the Diarrhea Treatment Units (DTU) are more intensively engaged in health education activities; they teach patients and relatives, for instance to prepare Oral Rehydration Solution (ORS). The Unit also provides proper diet for the severely malnourished children admitted in the hospitals. The mothers and the guardians are taught how to prepare balanced diet at home.

Nurse as an Educator of Patients

      Patient education is “a process of helping someone to learn through planned sequences of teaching, supportive activity, and directed practice and reinforcement” (Redman & Thomas cited in Leddy, S., & Pepper, J.M., 1998).  Nurses facilitate people to take care of their health. There is also pressure on the nurses to satiate the ever-increasing demands of the patients and public for better and efficient services due to advancement in medical sciences which has made detection, diagnosis and treatment of diseases easier. Nurses play an important role in the education of patients and public besides their routine tasks.

      According to the International Council of Nurses’ (ICN) code of ethics for nurses, the basic duties of nurses are to promote health, prevent illness, restore health and, alleviate suffering.  There fore, nurses not only educate patients such as, how to live normally with the diseases but also disseminate information to the public on healthy habits. In order to make the educative programs effective, it essential for the nurses to learn to design a formal health education plans and execute them professionally.

A well-designed health education plan aids in disseminating accurate information to the learners; it prevents deviation from the main theme of the teaching.  In the absence of a written plan, a teacher risks missing out important information which might cost lives. Giving health education on diabetic diet to patient in Bhutan, for instance, is strewn with hurdles due to different eating habits, socioeconomic status, lack of choice of foods and literacy of the patients. The concept of ‘balanced diet’ is still new in rural Bhutan. People are yet to recognize foods as the sources of vitamins and minerals essential for the smooth functioning of their bodies. This calls for cooperation from the patients as well as well as the teaching skills from the nurse educators. 

Often, it is erroneously inferred that the reason why the diabetic patients are repeatedly hospitalized is solely due to their non-compliance with the medical regimen. However, a closer look at the problem reveals that there are misconceptions and myths about the dietary requirements of diabetic patients: some patients completely stop consuming foods that grow under the soil; some patients eat only boiled rice, and so on. This could be interpreted to reflect poorly on the effectiveness of the health education on a condition called ‘hypoglycemia’ where the sugar in the blood falls below the normal level which is equally dangerous for the patients. There fore, the patients and their parties need to be educated on dietary aspect of the disease as much as on the medical aspect.  In order to be a successful patient educator, the health education plan must be designed and take into consideration all three domains of learning - cognitive, affective and psychomotor (Ray, 2004).

Nurse as an Educator of other Nurses

Teaching is not an exclusive domain of academic institutions. Nurses play an important role in the education of fellow nurses; nursing is acting collectively to achieve common ends. In order to achieve the common ends, nurses should be equipped with knowledge, skills and aptitude for learning and teaching.  Fitzgerald (2004) stated that, “[n]ursing is essentially a practice-based discipline that relies on its colleagues to provide professional learning support”. Nurses can learn better from each other without the fear of being judged as well as exert mutual check and balance by rectifying mistakes instantly.

Teaching and learning in nursing professions is in its elementary stage in Bhutan. Senior and experienced nurses lack time, opportunity and motivation to teach; the junior ones do not exhibit interest to learn. This attitude could be changed by the demand for quality services, as well as fear of prosecution for inferior or negligent services resulting in accidents and casualties.

There are many advantageous in learning from one another for a country like Bhutan which is still largely dependent on foreign aids. We are yet to have a medical college. Secondly, due to lack of fund, only a handful of nurses are trained outside. There fore, it is important that these few fortunate trained people in turn train fellow health professionals. A few nurses working in the Intensive Care Unit (ICU) of the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), for instance, were trained in Thailand in operating ventilator machines prior to setting up ICUs.  These nurses were then transferred to other hospitals to teach other nurses and staff.  Otherwise, the expensive life-saving machines will remain mere assembly of pieces of plastic and metal (Daly, J., Speedy, S., & Jackson, D., 2000).

Education of other nurses can be best achieved through clinical supervision (Fitzgerald, 2004). According to Goldenberg (1987, cited in Fitzgerald, 2004) clinical education is one-to-one relationship between an experienced nurse and a new nurse, where a new nurse is introduced to the work role. Accordingly, in Bhutanese hospitals, new nurses are guided by senior nurses in familiarizing with the working environment till they can perform their duties independently; nurse in-charges orient new nurses to the work place and introduce to other staff, as a preceptor (O’shea, 2002 cited in Fitzgerald, 2004).

Teaching-learning can also be achieved through mentorship system. A mentor is a wise, experienced and faithful advisor to an aspiring professional (Andrews & Chilton, 2000; Mundt, 2001, cited in Thrope, 2003); it involves developing a relationship between mentor and mentee (Morton-Cooper, 2000, cited in Fitzgerald, 2004), where the mentor assists mentee in empowering him/her within the work environment. The author, for instance was selected to work in the ICU at the JDWNRH which was dreaded at that time due to lack of skills in operating ventilators and the infusion pumps; secondly, the Unit cabins were mostly used by VIPs due to privacy afforded by the Unit. The author’s initial apprehension gave way to confidence as the nurse in-charge guided her in all aspects of the working of the Unit.

Nurse as an Educator of Self

In this era of globalization every one is competing against each other and trying to outsmart others.  There fore, nurses, can not definitely ‘stand and stare’ and afford to become obsolete or redundant. Each individual in nursing profession must put in their own share of effort in order to make nursing profession second to none. This requires the nurses to continuously update their knowledge and skills which inevitably involves teaching and learning. In this regard, Ray (2004) stated that:

The dynamic nature of the nursing profession means that nurses not only  need to teach others but they also need to keep themselves well informed to meet the ever changing needs of health care. Therefore it is imperative that every nurse takes responsibility for their own education and professional development (p.1).

Thus, the nursing profession requires the nurses to continue learning and acquiring skills thorough out their career. Self education empowers and equips nurses with necessary knowledge and skills which enhances their bargaining power in the global service market. It also increases the risk-taking capacity of the nurses and enables to make sound judgments and take informed decisions (Leddy, S., & Pepper, J.M., 1998). Knowing their jobs well helps nurses to justify the actions taken or the decisions made. Recently, a nurse was held accountable for negligence or delay in informing the doctor resulting in birth of a still born baby (Bhutan Times, 2007, July 29).

Increasingly, less doctors and nurses prescribe medicines from their consulting rooms to the submissive patients; they are required to explain or justify the correctness of the procedures carried out or the efficacy of the medicines prescribed (Leddy, S., & Pepper, J.M., 1998). Accountability is not a very familiar concept to many Bhutanese nurses; not many nurses have exhibited interest to revise what they were taught at the nursing schools, let alone building upon it.  However, lately, there has been pressure on this laid back or ‘who cares’ attitudes. Civil servants are not entitled for the annual increment of their salary if their performance is not rated well by their supervisors. Similarly, a civil servant will be denied promotion to higher positions if he/she does not have the requisite qualification required for those positions. There fore, it has become necessary to learn something, if not teach others.

Nurses can involve in learning by using various methods such as ‘Self directed learning (SDL)’ and ‘Reflection’. SDL is more preferred in adult as “their self-concept becomes that of a self directed personality”. (Knowels, 1980 cited in Kedall, S., 2007). And reflection is use of past experiences to make the present learning better and being able to reflect will promote the SDL (Ray, 2004).

Recommendations for Improving Nursing Practice

His Majesty the King has identified health and education as the priority needs for his subjects. We enjoy reasonably high standard of medical services in which nurses play prominent role. However, we must not rest on our laurels but constantly explore ways to improve at all fronts, including nursing practices. First of all, nurses must be eager and prepared to learn and teach fellow-nurses and patients. As an educator of patients, nurses must not only alleviate pain, but help patients cope with diseases and live with least anxiety. There must be adequate and relevant educative material on common diseases and, health issues and problems. Nurses should be proactive in organizing health education sessions independently. They should give proper instruction to the patients during their discharge from the hospitals on the follow up program and precautions to be taken.

Nurses should not only educate themselves but enlighten their colleagues on the issues and matters they are proficient in. They should encourage fellow nurses to read and update themselves with the latest nursing techniques and procedures. They should encourage fellow nurses to attend as well as organize clinical sessions and invite feed backs.

As an educator of self, nurses should advantage of every learning opportunity; participate actively in clinical session and keep themselves updated on latest medical developments, technologies and procedures; they should  initiate and propose nursing researches, practices on evidence-based practice and apply where ever practical.

Recommendation for Improving Educative Role of Nurses in Bhutan

According to a Bhutanese proverb, we must not stop learning even if you know that you are going to die tomorrow. History is witness to the fact that knowledge has ruled the world and, knowledgeable and wise people were always placed in higher pedestals in the society. Nurses are increasingly respected for their knowledge, skills and patience (Barnard 1997; Fairman 1992; Sandelowski 1997a cited in Daly, J., Speedy, S., and Jackson, D., 2000). There are many ways in which educative roles of Bhutanese nurses may be improved. There are not adequate opportunities for refresher courses, continuing education, and study tours out of country.  All nurses should be given opportunity to study, enhance their qualification and advance their career. They should be involved in literary activities, e.g., production of nursing journals, magazines, posters; and participate in discussions, meetings and conferences. They should also be involved in policy making process, especially the ones affecting them directly. They are not paid adequately compared to their western in other countries.  They should be provided basic furniture and office equipment. These may compel nurses to be more accountable for their actions. Above all, nurses should be trusted and respected, and their services acknowledged.

Conclusion

Nursing involves both learning and teaching. Teaching requires planning and considering ways in which people could be taught most effectively. More over, as Francis Baecon said knowledge must not hoarded but circulated freely.  Nursing practices increasingly demand analytical and problem-solving skills. However, nurses can not be an effective educator if they are not confident or well-informed. Nurses, like teachers have to facilitate learning. Secondly, learning is not simply acquiring, retaining or transferring information; the learners must benefit from learning.  

Teaching-learning activities help nurses to develop confidence to perform their jobs well as they can react or deal with people well. Once they are well read and informed, nurses will find teaching-learning activity enjoyable and learn to respond to the queries intelligently. The feed backs and criticisms will guide them in future teachings. Irrespective of public perception, nurses have no time to stand and stare. Criticisms indicate the visibility and indispensability of the roles played by nurses in the society. This compels us to keep learning and disseminate the information to patients, fellow nurses and the society on a daily basis.

My Journey towards Community Health Nursing(Assignment on PHC)

Introduction

Health has always received the royal patronage and priority of the royal government since the beginning of the planned development in the country in the 1960s.  It has been the attempt of successive monarchs and the Royal Government to make take health facilities as close to people as possible.  With health care services literally provided free of cost till date Bhutan has been described as a true welfare state. Secondly, we are a signatory to the Alma Ata Declaration and have, like many other countries, chosen Primary Health Care as the core health care strategy. As a result, rugged terrain, poor transportation and communication infrastructure have not daunted the royal government from taking the primary health care services to the most remote parts of the country. This is evident from the proliferating numbers of BHUs, Sub-Posts and ORCs (Bhutan 2020, p.54). There is likely to be grains of truth in our claim that 90% of our population live within three hours of walking distance. This Paper describes the concept of Primary Health Care, differentiates it from primary care and primary nursing and, analyses nurses’ roles and involvement in it.

Primary Health Care - Origin of the Concept

The Primary Health Care concept (PHC) is said to have been conceived at Alma-Ata in Soviet Kazakhstan during the international conference sponsored by World Health Organization (WHO) and United Nations Children’s Emergency Fund (UNICEF) (Wass, A. 2000, p.263). The Conference officially acknowledged the PHC concept as the key element to achieving the WHO’s goal of ‘Health for All by Year 2000’ (HFA) in order to bring about changes in the existing inequalities in health care delivery system; it declared that good health should be considered as the fundamental right of every individual in the community with collective duty and equal chances for improvement of the socioeconomic status.

Primary Health Care - Definition

According to the Alma Ata Declaration, Primary Health Care “is an essential care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work” (p.15).

The Guiding Principles of PHC

The five guiding principles of the PHC concept are: (1) Health Prevention and Promotion, (2) Equity, (3) Appropriate Technology, (4) Community Participation, (5) Inter-sectoral Coordination and Decentralization. PHC emphasizes more on prevention of diseases, rather than cure; it facilitates community participation and the recommends technology that is culturally acceptable; it takes affordability of the people in the community into consideration. In general,  PHC is intended to meet the needs of an individual and the community at large through a national health care system by taking the preventive, promotional, and rehabilitative services as close to them as possible by the trained healthcare personnel.

In order to ensure that the universal coverage of first contact care is achieved, PHC functions the following components:

(a)    health education concerning prevailing health problem,

(b)   promotion of food supply and proper nutrition,

(c)    adequate supply of safe water and basic sanitation,

(d)   maternal child health including family planning,

(e)    immunization against major infectious diseases,

(f)    prevention and control of locally endemic diseases,

(g)   appropriate treatment of common diseases injuries and,

(h)   Provision of essential drugs.

The main characteristics of the PHC are equity-oriented, improved healthcare services coverage among the poor and empowerment of the vulnerable groups to have more central role in health system design and operation. PHC services emphasises on health promotion, prevention of diseases and rehabilitation. The services are effective, acceptable to all the members of the community and do not have financial, geographic, organizational, socio-cultural, and gender-based barriers to access. The communities are actively involved in making decisions about resources, selecting priorities, and ensuring accountability. They also evaluate the implemented programs. The approach to health is by involving health service collaboration and multi-disciplinary partnership, in order to prevent the consequences of ill-health as a result of the failure of other sectors; which makes it is important to work together with other sectors for the common goal.

Primary Health Care versus Primary Care or Primary Medical Care

However, PHC is neither Primary Care nor Primary Nursing.  Primary Medical Care or Primary Care is the care received by the individual during his/her first contact with the health care facility. The medical cares are provided by the general medical practitioners or in the out-patient department in the hospital settings. (Source) The medical care providers can also be physicians, nurses, dentist, physiotherapist and other health professionals.  In Bhutanese context, for instance, primary medical care provided at the Basic Health Units is manned by Health Assistants (HA), Auxiliary Nurse Midwifes (ANM) and Basic Health workers (BHW). Here, the care provided by these health workers depends on the severity of the illness and the knowledge and skills of the health workers; if the cares needed by the patients are beyond their knowledge and technical capacity they refer the patients to the next higher medical facilities, for instance, a district hospital or a regional referral hospital.  At the district or referral hospitals, the primary care is provided in the Casualty Units by the nurses on duty or by the physicians on call. In hospitals where there are no separate Casualty Units, the nurses on duty provide the primary care and seek the help of concerned physicians.

Primary Health Care versus Primary Nursing

PHC is not Primary Nursing - primary nursing mainly means that a particular nurse is assigned to take care of a particular patient where the provision of care is still on curative purposes. In this type of care, the level of care is very narrow as the target of the care is not the community, but an individual. And, in Bhutanese context, this system of nursing care does not exist because number of patients admitted almost always outnumbers the nurses on duty. Although it is yet to be officially credited, presently, nurse functions as a multi-skilled personnel taking care of all the patients admitted in a particular. 

Role of Nurses in Primary Health Care

It is observed that the global nursing profession’s response to HFA by adopting the PHC practices was quick and enthusiastic (Patterson, E. 2000).  The International Council of Nurses (ICN) who represented the nurses submitted their statement of commitment to embrace PHC practices to bring effective changes and contribute to the implementation of PHC during the 1978 Alma-Ata Declaration (Krebs, year ??), cited in Patterson, 2000).

After the Alma-Ata Declaration, the WHO in collaboration with international nursing bodies, suggested that nurses should initiate active participation with the inter-professional teams; they would act as leaders in the health care and be the resource to the communities (Patterson, E. 2000). Since then, nursing and midwifery personnel are the major service contributors of the PHC in many countries. A WHO committee in 1984 (K.park, 2004) has defined the role of nurses in PHC as:

1.       Assessing the health status of individuals and communities, mobilizing community involvement,

2.      Providing integrated health care including the treatment of emergencies, and making referrals,

3.      Making epidemiological surveillance, Training and supervising health workers, collaborating with other development sectors, and

4.      Monitoring progress in PHC.   

In many countries, nurses associations have formed their own committees to monitor the strategies of the nursing works in support of the PHC. Primary health care in India is provided by health guides and multi-purpose workers – both male and female health workers. In Australia too, many studies were conducted to assess the contribution to PHC by the nurses who are working in the general medical practices (Patterson, E. 2000).

PHC Practices in Bhutan

The modern health care system was formally established in the year 1960 in Bhutan.  After the Alma-Ata Declaration, Bhutan formally adopted the PHC approach in 1979 (Master Plan for Human Resources for Health in Bhutan, 1998, p5). The present health care system caters PHC to 90 % of the population. The Basic Health Units (BHU) provides the primary level services to the communities and individuals. There are also Out-Reach Clinics to provide the services to those residing in the rural communities (M, Geeta, 2005). Consonant with the PHC principle of involvement of the community,   Village Health Workers (VHWs) was institutionalized in 1978 by Helvetas in Bumthang. The VHWs disseminate information related to health and environment to the communities and serve as links to the higher health care facilities.  

It is the policy of the Royal Government of Bhutan to enhance the quality of the life of the Bhutanese people through improved health care and education (Master Plan for Human Resources for Health in Bhutan, 1998).  It has always been the aspiration of the RGoB that all people are healthy and happy.   PHC activities are carried out by the several programs under the Public Health Department with emphases on preventive and promotive strategies which are supported by adequate curative measures (see Appendix I).

The nurses and other paramedical workers undergo rigorous and long training at the Royal Institute of Health Sciences (RIHS). It churns out different categories of nurses, such as General Nurse Midwives (GNMs), Assistant Nurses (ANs) and Auxiliary Nurse Midwives (ANMs). The training prepares the nurses to work at any level of health care setting and facilities – preventive, promotive or curative aspect although the job description and responsibilities will differ according to the places of posting and the type of nursing category one is trained in. The duties and responsibilities of ANMs according to the Royal Civil Service Commission (RCSC), for instance, are presented in decreasing order according to the percentage of time spent on each activity or in accordance of their importance (see Appendix II).

Conclusion

The PHC has served well and is likely to be around for foreseeable future. However, as simple as it sounds, the concept of PHC demands hard work and genuine efforts for effective results. The concept must permeate the entire health care system and staff manning the system and the members of the community should interact meaningfully. Above all the health care workers, specially the nurses must own the concept and be guided by the principles of PHC while discharging their duties.

The PHC’s main thrust is on social justice, equity and community participation.  The health care services and related technology must not only be socially acceptable but affordable. Further, the services should cater to the needs of the people and, people must be educated and or made aware to prevent eliminate the causes of the ill-health or seek timely medical services.

Health care perspective (Nurses' point of view)

Introduction

Bhutan is a small Kingdom situated between China and India. Health and education sectors received priority since the inception of planed development in the Kingdom; both services have literally been provided free of cost. The draft Constitution envisages “free access to basic public health services in both modern and traditional medicines” (Article 9(21), p. 15). This Paper seeks to identify the major health problems affecting the Bhutanese population and analyze selective strategies of the 9^th Five Year Plan (FYP). It also presents a panoramic view of the existing Bhutanese health care system, the challenges which lay ahead and the ways in which health care personnel in general and nurses in particular can contribute towards fulfilling the Royal wishes of maximizing the Gross National Happiness of our people.

Background

Health is defined as “a complete state of physical, mental and social well being and not merely the absence of the disease or infirmity” (WHO, 1948). Modern health care system came to Bhutan in the early 1960s with the launching of the 1^st FYP (1962-1967) during the reign of the third King. Beginning with the adoption of primary health care approach in 1978, Bhutan achieved a rapid improvement in the health care delivery to its population. Bhutan’s health care system is a blend of traditional and modern allopathic medicines. In congruence with the Royal Government’s planning policy the Ministry of Health set up its plans as, ‘Five Year Plan’. Accordingly, the 8^th FYP (1997-2002) aimed to achieve ‘health for all’ by the year 2000.

Major Health Problems

The predominant communicable diseases in Bhutan are tuberculosis, leprosy, malaria and Human Immuno Virus/Acquired Immuno Deficiency syndrome (HIV/AIDS). Non-communicable diseases are mental illness and lifestyle diseases, for instance hypertension and obesity. It is feared that people may become vulnerable to combination of communicable diseases like AIDS and Tuberculosis.

The prevailing top ten diseases are common cold, skin infection, peptic ulcer, other musculoskeletal diseases (other than arthritis and arthosis), acute pharyangitis/tonsilites, diarrhea, other disorders of skin, conjunctivitis, other diseases of digestive system excluding dental carries, diseases of teeth and gums, acute appendicitis, alcoholic liver disease and gall bladder disease, followed by antenatal check up/immunization (Annual Health Bulletin (AHB), 2006, p.9). The trends of morbidity among the children under five are the top three diseases, common cold, diarrhea and skin infections, causing 50 % of the total morbidity (AHB, 2006, p.7).  

In terms of mortality, the alcoholic liver disease contributed to 7.8 % of the total deaths in last three years. Postpartum hemorrhage is the leading cause of the maternal mortality followed by severe pre-eclampsia /eclampsia (AHB, 2006, p.7 & p.47). Due to strong patronage emanating from the Throne and Royal Government’s commitment, small pox has been eradicated in 1976/77; leprosy and iodine deficiency disease has been eliminated in 1997 and 2003 respectively.

Funding

As evident from the fund allocated, Royal Government continues to ensure that the provision of health services is not compromised. 22% of the national budget is allocated to the health and education sectors out of which 8.5% is allocated to the health sector (Wangchuk, N., http://www.whobhutan.org.htm). These sectors have also received the maximum grants aid since 1991 amounting to Nu.6.7 billion. Similarly, these sectors received the highest grants receipts amounting to Nu.945.2 million in 2005-06.  As a whole, health and education sectors received 17.40% of the total grants during 2005-06 which is comparatively the highest (Kuensel, 2007, March 24).

Lately, cost-sharing practices have been initiated in selective services (for instance, cosmetic dental and laparoscopic surgeries for removal of gall bladder stones) during the 8^th FYP in pursuance of the policies of self-reliance and sustainability; people are also charged for hire of cabins/private rooms in the hospitals. Monthly compulsory deduction at source of health contribution from civil servants is not a new practice. However, unlike Australian health care system there are not much cost “mutualisation in pharmaceutical” commodities (Duckett. P.9, 2004) in Bhutan; patients are required to buy certain drugs which are not in the essential drugs list as the last resort.  Initiating Health Trust Fund with the intended capital of US $ 24 million is aimed at providing free vaccines, one of the important health care services.

Organization

The Ministry of Health in an independent ministry headed by a minister and supported by a secretary. It has two Departments – the Department of Public Health and the Department of Medical Services, each headed by a director. There are other special units like Bhutan Medical and Health Council, Internal Audit Unit, Information Communication Unit, Legal Unit, Drug Regulatory Authority, Policy and Planning Division, Quality Assurance Division, and Administration and Finance Division. There is Institute of Traditional Medicine Services under the Department of Medical Services.

Health Care System

The Bhutanese health care system is founded on concept of primary health care based on the principles of equity, accessibility, acceptability and affordability. It is an integrated system catering primary health care to, ‘90% of the population’ (Statistical Yearbook of Bhutan, 2004). It functions through four-tiered system of (1) the Basic Health Units (BHUs), (2) the district hospitals, (3) the regional referral hospitals and (4) the national referral hospital.  Medical cases, for instance cancer, which can not be treated in the Kingdom, are referred to India.  

Health Assistants, Auxiliary Nurse Midwives and Basic Health Workers staff the BHUs. They take the health care services to the remote areas of the Kingdom through monthly out-reach clinics (ORC). The Village Health Workers serve as bridge between the community and the health workers.  The district hospitals are manned by one or more doctors and the national and regional referral hospitals provide selected specialized services. This is supplemented by traditional medicines; all the districts have indigenous units attached to the hospitals.

There is no method of measurement of the services in terms of inputs and outputs like that of Australia (Duckett 2004, p.2); the achievement of the health care services in Bhutan is analyzed at the end of the FYP as the targets are set at the beginning of the Plan.

Selected Strategies and their Implication on Nursing Services

The 9^th FYP witnessed significant milestones in the history of the Bhutanese health care system. The Plan saw achievement of almost all the goals set in the previous Plans. There has been a shift of focus from infrastructure development to providing the quality services at each tier of health care services delivery system as evident from the selected strategies discussed below.

I. Enhancement of the Quality of Health Services

One of the most important strategies of the 9^th FYP is the enhancement of the quality of health services. The introduction of quality assurance program saw all-round development; there is quality assurance team at every level of health care system. However, the standard of the quality assurance and their rules may vary depending on the local needs and circumstances.

Information technology, especially in a mountainous country like Bhutan plays a vital role in the enhancement of quality of health care services. A doctor in a remote hospital, for example, can confidently treat patients by consulting specialists either over the telephone or with the use of telemedicine facility. This will improve with the increasing coverage of the Kingdom by telecommunication services.

There is effort to ensure a consistent supply of all five important vaccines, namely, BCG, Measles, OPV3 and DPT- Hep B. We’ve achieved 90 % coverage in the immunization of children below one year. In 2005, there was 100 % BCG immunization.  Measles and Rubella (MR) vaccines have been introduced in 2006; the intensive campaign achieved 98 % coverage. Since then, MR vaccines are administered at 9^th and 24^th months (AHB, 2006, p.8).

Much has developed at infrastructure front too. The construction of regional referral hospital at Monggar and national referral hospital at Thimphu are nearing completion. The number of BHUs has also increased from 166 in 2002 to 176 in 2005. There are 485 ORCs serving as the main outlet of primary health care to the most interior parts of the Kingdom. There are 21 indigenous units (AHB, 2006, p.4). A CD4 level counting machine has been installed at Mongar regional hospital. At the diagnostic front, installation of Computed Tomography scan and Magnetic Resonance Imaging equipment has enhanced the quality of health services.  This will also save fund in terms of decreasing referrals outside the Kingdom in the long run.

The Medical and Health Council Act 2002 regulates legal and ethical matters pertaining to delivery of medical services. The Medicine Act 2002 ensures the quality, safety and efficacy of the medicines. However, with the increasing literacy of the population health personnel may play safe due to legal implications which may arise from medical negligence. Consequently, public may be fed with defensive services and complex statistics.

Being at the forefront of delivery of medical services, better infrastructure, state-of-the-art-technology, good legal framework and farsighted policies will facilitate the nurses to deliver better and faster health services.

II. Target Health Services to Reach the Un-reached.

Reaching the un-reached is yet another important strategy of the 9^th FYP.  Although we claim 90 % health coverage, existence of certain pockets of areas where health services have yet to reach can not be ruled out since Bhutan is a Baeyul (a hidden land) with rugged terrain and harsh climate. The nomadic population, floating population, religious population, groups’ not availing services and, communities not covered by health facilities are recognized as un-reached populations which are of rural setting and urban setting. Introduction of satellite clinics at the capital has been aimed at catering to such groups; besides faster delivery of services, it is expected to mitigate the patient load at the hospitals (Pelvar, S. Bhutan Times. 2007, April 8). The increased number of ORCs and creation of Sub-Posts is expected to take the medical services closer to the people in the far flung areas.

However, despite our full efforts and the best intentions, there may be more hidden and mysterious places like Yoserna (Tashi, T. Bhutan Time. 2007, March 25). One can only wonder about the diseases and epidemics afflicting these people; for instance sexually transmitted infections, one of the precursors of HIV/AIDS have not spared even remote Gasa. Thus, while the veracity of our claim for 90% health coverage may not be doubted, we should not cease to attempt to reach the un-reached.

III. Prevention and Control of Prevailing, Emerging and Re-emerging Health Problems.

Intensification of activities for the prevention and control of prevailing, emerging and re-emerging health problems is yet another important strategy of the 9^th FYP. This pertains to both the communicable and non-communicable diseases. HIV/AIDS, road traffic accidents, alcoholic liver diseases, hypertension, and lifestyle related diseases, rheumatic heart diseases, severe acute respiratory syndrome (SARS), hepatitis, cancers, meningitis, ageing, occupational health, substance abuse and avian flu are the emerging issues. Tuberculosis, dengue/dengue hemorrhagic fever and Japanese encephalitis are re-emerging diseases. Information, communication and education on avian flu are also disseminated (Namgay, S. Kuensel. 2007, February 28) since we not only import poultry products but raise it in traditional ways.  Further, due to rich biodiversity Bhutan provides roosting places to the migratory birds like black necked cranes which might carry the virus. Out breaks of dengue fever may be managed better if fund is instituted for the same.

Assistance and cooperation of the community is enlisted while combating the diseases. Comprehensive guidelines have been developed to take care and treat the opportunistic infections of the HIV/AIDS. The Anti-Retro Viral drugs are now available. People are trained for Voluntary Counseling and Testing (VCT). District Core Teams have been identified for the care of HIV/AIDS cases and, autonomous VCT centers have been opened at Thimphu and Phuntsholing.

If we are not vigilant, substances abuse may become public health problem with increasing number of young children getting inside the trap (Dema, K. Kuensel, 2007, March 3 & Wangmo, T. Bhutan Times, 2007, March 11). Frequent arrest of the drug peddlers and seizure of vast array of drugs by law enforcement agencies indicates that the Ministry should step up measures to curb the emerging problem.

The non-communicable diseases programs have also been intensified. Diabetic clinics have been opened in Thimphu and Mongar hospitals which are staffed by trained personnel. Papanicolaou (Pap) smear screening facilities for early detection of cervical cancer have also been extended to almost all the hospitals and BHUs.

Conclusion

Bhutan has made considerable progress in developing an integrated decentralized heath care system within relatively short span of time. There are continuous efforts to reach the un-reached parts of the Kingdom. At the same time, no effort is spared to improve the quality of the existing system, including - primary health care, disease control programs and needs of the disabled, the elderly and, the emotionally and mentally disturbed (Bhutan 2020, p. 55).

Traditional medicines have been nurtured as an alternative medicine. We are keeping abreast of developments in the medical world. Telemedicine is contributing to the quality and effectiveness of delivery of health care services especially in remote districts. We are also conscious of the cost and sustainability of free health services and the people are accordingly sensitized by levying charges on selected services.

Most importantly, people at the forefront of the health care system – the doctors, nurses and health workers are continuously trained, and the days may not be far when the our system is fully manned by Bhutanese. With strong leaderships of the successive monarchs, stable government and small population (672,425; AHB, 2006),  we can achieve  100%  coverage in the delivery of improved health care services in the near future, thereby  maximizing the  gross national happiness of our people.

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