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.