Positive Communication in Nepal
If you were to ask nurse Katie Osborn, RN, to sum up her accomplishments from a recent trip to Kathmandu, Nepal in two words, it would probably be “better communication.” Katie has been working as a volunteer with ReSurge’s visiting educator (VE) teams for over 20 years. Each time she goes to a country, there are typical communications barriers, such as language and cultural differences. But this trip, which took place at the beginning of February 2020, provided a significant opportunity to improve communications efforts on the ground.
The VE team included Katie, Dr. Tam Pham, a burn surgeon, and Dr. Carey Pilo an anesthesiologist, who partnered with ReSurge International Medical Partner, Dr. Shankar Rai. Dr. Rai is always welcoming our ReSurge teams, especially this time of year. During this winter season, the burn center at his hospital receives a major influx of patients who sustain flame burns, most after warming themselves over an open fire. These injuries primarily affect women who wear longer clothes, and the injuries are deep, centered around the buttocks, perineum and posterior lower extremities. His burn unit, which has approximately 30 beds and a six bed Burn Intensive Care Unit (ICU), are overflowing so the extra hands were much appreciated.
The task of the Visiting Educators is to provide education for the local nurses and doctors both in classroom and clinical settings, including surgery. After observing and teaching for a few days, the VE team recognized a great need for better communications.
Dr. Rai has five outreach hospitals throughout the country. Often burned patients go to these outreach centers first, are stabilized and then sent to the main hospital, which for some, is hours away. Other patients come from all over Nepal directly to the hospital in Kathmandu. It had been reported to the VE team by previous medical teams that the patients arriving from the outreach centers and those who came directly or from other clinics were not as stable as they should be in terms of fluid resuscitation and initial wound care. The team was told that many of these patients were suffering from dehydration due to massive fluid loss from their injuries. There needed to be better communication given to the outreach centers on stabilizing these patients before sending them to Dr. Rai.
Katie provided lectures to the nurses from these outreach centers about the need for fluid resuscitation and wound management prior to transfer. One of the nurses was the educator for the nursing staffs at all the outreach centers. Katie spent three days educating her and providing educational materials for her to use in her training. Katie continues to email correspond with her, providing additional requested materials to be distributed to the outreach centers.
Another communication issue Katie witnessed was the observed inability of the nurses to alert the doctors to a patient’s changing status at the Kirtpur Cleft & Burn Hospital. The VE team observed that frequently by the time the patients were transferred from the Burn Ward to the Burn ICU, the patients were very sick, often with burn sepsis. Timely reporting and treating of burn sepsis impacts patient’s ability to survive. The team agreed that education about early signs and symptoms, and treatment of burn sepsis was needed.
Katie lectured to about 25 nurses over a two-day period on comprehensive burn care and the need for ongoing communication regarding burn sepsis. The nurses were taught how to use the SBAR (situation, background, assessment, and recommendation) tool. As a case study, Katie referred to the three patients that currently had been transferred to the ICU due to sepsis. She outlined the sequence of events that occurs with sepsis in order to stress the critical nature of early reporting and intervention.
Culturally, Katie observed that many of these nurses did not feel empowered to speak up if they saw a problem with their patients. Or, if they did, often the doctors did not listen to their assessment. We found that most of the patients in the burn ICU were dying from sepsis, a condition that if closely monitored and reported, increases survival rates.
It is important to note that in a burn unit of 30 beds in the U.S., you would most likely have over 25 nurses assigned. However, in this burn ward, there were only 4 nurses available per shift. There is a nursing shortage in Nepal, with many nurses leaving the country to find work in better paying countries.
The team found it important to present the lesson of open communication not only to the nurses, but also to the doctors. Katie stressed to the physicians the importance of timely and accurate communication. In one lecture, it became clear that the doctors were not heeding this message.
“Dr. Rai, who was attending physicians’ lectures, jumped right in and explained how critically important it was for the physicians to work closely with the nurses,” Katie said. “Not only did he hold the physicians accountable for maintaining this relationship, he attended one of the nursing lectures and told the nurses that if a doctor is not listening to you, go over their heads to the next higher up provider. This is a totally foreign, revolutionary concept for these women and a sign of change.”
Overall, the VE team conducted 16 lectures with 172 participants, and performed 10 operations.
“We accomplished many things,” said Katie. “But I think the message of better communication will really be the legacy left behind. With the support of Dr. Rai, we can already see a shift happening. I feel confident we made a difference.”