Teaching nursing students in Uganda

“Meet them where they are.” For a nurse, this principle could mean learning about a patient’s health awareness before providing health instruction. For a teacher, it might mean assessing students’ knowledge before teaching a topic. But what does this principle mean when a nurse instructor from the United States teaches nursing in Uganda?

Similarities

As a teacher at a University in Uganda, my job includes lecturing in the medical-surgical nursing course to third-year nursing students. On arrival, I found that the nursing program curriculum, clinical expectations, and course structure are similar to those in the U.S. Even the textbooks are from the U.S. In fact, one is the very same textbook that I have used to teach nursing in New Hampshire.

Making adjustments

Peace Corps service is replete with adjustments. In fact, that is why many of us chose to serve. As I started to teach, I had to adjust to the physical setting, the students, the prevalent health conditions, and the available resources. It was a steep learning curve. My role was limited to the classroom environment and not the clinical one, so I had limitations regarding the realities of health care delivery in the wards. The realities I could not see included less staffing, fewer supplies, and more limited technology than in my U.S. hospital. To better understand the wards and their challenges, I toured them with staff. During class time, I asked the students to tell me about their clinical day and patients they cared for.

Recognizing my blind spots

Even so, it was hard for me to gauge how my U.S. perspective translated to the lower-resource health care environment of the hospital. One day, when discussing strategies for post-operative pain control, I suggested applying an ice pack on a patient. The students looked at each other and laughed! This is a low-resource environment. Supplies are often limited or unavailable. Ice, for example, is unheard of in the wards. I wondered, how often do I miss the mark like this? Is my teaching even relevant? How can I meet my students where they are?

Creativity is the key

I began looking at those U.S. textbooks with a more discerning eye. Modern evidence-based standards and protocols for health care are great, but what happens when teaching health care in a lower-resourced environment? Teaching the “modern” protocols is unhelpful at best, if limited staff support, experience level, and supplies are completely unrealistic. The challenge, how do I adapt expectations to the Ugandan context?

Local context and relevance

Ugandans care about their patients and they are committed to providing quality care. They have adapted their care to the resources available. To learn more, I started reviewing the Ugandan health care research (in contrast to western textbooks and articles) as I prepared each lecture topic. I noticed that in the recent decade, health care research in Uganda by Ugandans has exploded. Many studies are emerging from the teaching hospitals associated with Makerere and Mbarara Universities, for example. As I reviewed these studies, I learned about health care and issues in Uganda. I learned how different the information can be from conventional western health care knowledge, or even information from the World Health Organization and other multinational organizations that guide global health.

Examples

1. PUD and gastritis. I taught a nursing care lecture about peptic ulcer disease (PUD) and gastritis. These diseases have higher prevalence, for multifactorial reasons, in Uganda than in Western countries. I reviewed with the students several sources that considered the higher prevalence of PUD/gastritis in rural Uganda as related to contributing factors such as hygiene and clean water availability. I asked students: Suppose you, as a Ugandan nurse, wanted to reduce PUD prevalence. What are the primary and secondary prevention strategies you would employ? Class discussion popped out some great ideas – ideas informed by the actual Ugandan research and students’ own knowledge of their country. Obviously, this approach is not rocket science. But with it I hope to encourage students to learn and think beyond the (conventional, high-resource, and not always relevant) western texts that nursing education often relies upon.
2. Chest tubes. I was assigned to teach the students about managing chest tubes, which are relatively simple but extremely effective devices that help drain excess fluid or air from around the lungs. After a doctor places a chest tube, nurses monitor and manage that device in the hospital. The device may be simple, but competency to manage the device safely is not. Nurses in the US are trained with standard procedures to minimize risk of infection, backflow of air or fluid, and other potential harms. In the U.S., a chest tube drains into a single-use safety-engineered collection device that costs $50-$100 or more. As I prepared to teach about chest tube management, I kept asking around for a device from the hospital with which I could demonstrate and practice the skill with my students. Finally, during lecture, my students explained what is typically used in the Mbale hospital: a repurposed drinking water bottle and a drainage tube that the surgeon has placed using whatever supplies are available. Ahhh, I thought, Ugandans are so resourceful.

Solutions lie with students

I had prepared a PowerPoint lecture teaching western-style device management and standards that were not relevant. So, I asked the students: How do we adapt these concepts to the Ugandan environment? We discussed how to manage a Ugandan-style chest tube with consideration of risks and safety goals, similar to the textbook standards, but adapted to the available equipment and supplies of the hospital. When one student came forward afterward and asked me worriedly about her patient with a chest tube that was bubbling a little after she emptied the collection bottle – I knew she had understood the concepts. Another score for student-led adaptation.

Sepsis. In a lecture about orthopedic patient management, one of my students discussed his patient with a septic surgical wound. (Septic infections can cause significant mortality.) It emerged that this patient’s sepsis was likely exacerbated, if not caused, by the health care environment and care providers. I asked the students to discuss all the contributing factors that they could see – and there were many. I collected and summarized their observations and ideas for them. Then, I asked: When you are a nurse, or even now as a nursing student, what can you do to begin to address these problems? They had many robust ideas. We grouped the ideas into strategies for now and for the future. Sepsis prevention is a topic we revisit often. Sepsis is rooted in conditions that would not be accepted in a U.S. hospital but are normalized here in Uganda. But we are two countries with different histories and resources. Of course, solutions developed in the U.S. do not fit like a glove in Uganda! From what I am learning, it is unhelpful for a more-developed health care system to attempt to direct-transfer its norms to Uganda. I know I am not the first person to learn this obvious fact, but to some extent, maybe we all must learn the lesson ourselves when we serve in the Peace Corps.

Listening and adopting

During my Peace Corps Volunteer service in Uganda, I can unequivocally say that listening is the most powerful tool and the most effective path to success. Listening and adapting my teaching to what I learn from my students can make my teaching more relevant. Listening and adapting health care to the Ugandan context is key and the solutions lie with the Ugandan students. Empowering the next generation to lead with their own ideas: that is how improvement takes root.