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Nurses build their strength

Sister Sabitri Sunwar takes care of dialysis patient Tsheltrim Dema. Sr Sabitri and her colleagues have been working with Australian volunteer Jane Nicholson to strengthen their knowledge and skills in dialysis. 

Through a mix of bedside teaching and professional development workshops, the hardworking nurses in Bhutan's main referral hospital have been honing their specialist skills.

Zero cases of polio since 1986. Maternal and infant mortality rates significantly reduced. Life expectancy almost doubled from 37 years in 1960 to over 68 in 2012. Fewer deaths due to diseases such as tuberculosis and malaria; and the endemic goiter and leprosy eliminated. Bhutan has made impressive progress in the past few decades towards improving public health and is well on track to achieving - and possibly exceeding - several health-related millennium development goals.¹

These are significant milestones, but an acute shortage of doctors, nurses and skilled health workers still challenges the health system, with only 2.6 doctors and just 9.8 nurses and midwives per 10,000 people.²  Meanwhile demographic, epidemiological and environmental changes, including rapid urbanisation, are now presenting new health challenges.

The Australian Volunteers for International Development (AVID) program is working to improve access to high quality health services in Bhutan by partnering with the Jigme Dorji Wangchuck National Referral Hospital to enhance staff capacity in primary healthcare and specialised clinical services.

Dialysis and Post Anaesthetic Care Unit nursing (previously known as 'recovery nursing') are two crucial areas where Australian volunteers have been working with clinical staff to strengthen knowledge and skills.

The National Referral Hospital has a small dialysis unit, with eight machines serving up to 100 patients a week - and that number of patients is fast growing. Urbanisation and modernisation has seen a rise in lifestyle- related conditions such as diabetes and hypertension, leading to an increase in kidney failure.

Dialysis nurses in Bhutan complete about four months' training in either India or Thailand, but few have the opportunity to do any further professional development in their specialised field. This is one of the staff team's greatest challenges.

Sydney-based renal nurse Jane Nicholson worked side by side with the unit's 11 nurses, mentoring and teaching through bedside practice. Jane has introduced several safer dialysis practices such as full priming, a technique that involves administering saline before starting patients with low blood pressure on dialysis to prevent their condition from worsening.

"Sister Jane also taught us a better closing technique after finishing dialysis, with this there is less chance of air embolism or blood loss," says Sister Sabitri Sunwar, Nurse in Charge of the Dialysis Unit.

Infection control was another focus of Jane's assignment. She initiated the "5 Moments of Hand Hygiene" protocol, which saw alcohol hand wash placed at each bed, changing linen between patients and regularly cleaning dialysis machines and treatment areas become standard practice.

Jane also delivered formal training sessions covering a wide range of topics including infection control, hepatitis, complications of dialysis and anaemia, as well as delivering two workshops for a gathering of all renal nurses from across the country.

Increased urbanisation has also led to a rise in traffic accidents and occupational safety related incidents in Bhutan. This is just part of the reason why staff in the hospital's busy operating theatre, which has eight rooms, performs surgery on 20 patients a day - an average of 140 cases a week.

Great progress has been made in the Post Anaesthetic Care Unit with support from Dallis Fellows, who took a hands-on role helping staff to develop their knowledge of this speciality, starting with the basics.

"We physically had the recovery unit [before Dallis arrived] but we did not have any trained staff in the unit. Since she came there has been lots of improvement through teaching and guiding," says Nursing Superintendent Tandin Pemo. "She taught staff how to observe, how to monitor vital signs, and also introduced a nursing record."

Now, as matter of course, nurses record observations including the patient's blood pressure and pulse, the condition of any drains or dressings and - crucially - their airway status.

"When the patient doesn't fully wake up and protect their own airway this is when the most deaths can occur, so I taught staff how to support a patient's airway," says Dallis.

The staff team now also use the Aldrete scoring system, which is used in many hospitals throughout the world. If a patient scores below nine the nurses know that the patient is not yet stable enough to return to the ward.

Head of the Post Anaesthetic Care Unit, Tek Nath Mishra, says improved post-operative monitoring and recording is already having a much broader impact.

"This is very important and is required as a basic standard," he says. "Now also in the ward they can see changes in the patient's status and this can be used for treatment."

The hospital aims to increase the number of trained nurses in the operating theatre recovery unit in the future and continue to strengthen the skills of staff in a neonatal and adult intensive care

Superintendent Pemo believes the AVID program can play a key role in these areas. "The nurses here are very hard working - the workload is more than three times more than other district hospitals and they have to work really hard with the knowledge they have. So it's good to have the volunteers here… better education in these specialised areas will benefit our hospital and our patients."

The Australian Volunteers for International Development (AVID) program is an Australian Government initiative. Red Cross is one of three delivery partners for the AVID program.

¹ Bhutan: Health Profile, World Health Organisation, May 2014 (data from 2013).

² Bhutan: Country Cooperation Strategy, World Health Organisation, May 2014.