The main purpose for our trip to Bhutan is to, as nursing students learn about and from their healthcare system. Our first exposure was info sessions on Bhutan, GNH and their healthcare system at RIHS.
Gross national happiness:
GNH is born out of Buddhist teachings that became a legal code in 1729 based around the concept that if you cannot create happiness for yourself and more importantly others then you have no purpose to exist. In 1987 their 4th king stated that it's more important than GNP. It's a holistic measure of the quality of the country based on serving others, nature, and recognising your own innate personal wisdom and brilliance. There are 4 pillars 1) socioeconomic development 2) culture 3) environment 4) good governance. The end goal is to promote the common good and conditions to sustainably peruse wellbeing.
We learnt a lot about what different demographics ranked as being most important to happiness, with financial security consistently being at the top. Conversely to what we believed it would be in Aus, leisure time was always down the bottom. As part of GNH healthcare is easily accessible and free. It's been shown that 98.6% of the population are happy with the system, I don't know the aus equivalent but I can't imagine it would be that high!
Healthcare in Bhutan:
- **Disclaimer: nursing rant, it may be ridiculous and not mean much to non medical people and I have tried to be minimally gory, but apologies in advance***
Health delivery only became prevalent in Bhutan 1961 with the introduction of the first 5yr plan and the development of 65 basic units and 22 hospitals. Before this their health indicators were among the lowest in the world and relied on drs from overseas. In 1974 RIHS was established enabling them to begin to self rely on manpower.
Currently there are 181 drs, 723 nurses, 572 health workers, 31 hospitals and 181 basic medical units throughout Bhutan. There are currently 555 people to a bed within the health system.
Their present system is essentially a 6 tiered referral system.
Firstly is the outreach programs consisting of 1200 volunteer health workers who are trained in hygiene, water education, immunisations and family planing and can give basic meds
Next is the basic health unit, there are several of these in each Geog (equivalent to a state in aus), they can treat minor illness and injuries. If a patient cannot be treated they are referred to the district hospital where there are 3drs, 20 beds and qualified nurses, next is the regional hospitals (east, central and west) for complicated cases and where some specialities are available.
Finally is the national referral hospital in Thimphu. Here there are resources such as CAT/MRI and sub specialists. If someone cannot be treated here, e.g needs open heart surgery they are referred to India.
It was at the national referral hospital we did x2 observational nursing shifts. We had a tour of the hospital one afternoon and it took me a long time to realise what I thought. It was like walking through a movie set. It wasn't as crowded as I expected and a lot bigger, but it was very dark, rundown and eerie. There was so many infection control issues, something that came up again and again, no patient privacy with up to 8 people in a room. However I did have to question, just because it's older equipment then I'm used to, does that make it bad? The nurse:patient ratio is as high as 1:18 but if that's what they have learnt from the start, maybe it works.
In a county that until so recently has no major health services, surely this is better than nothing. I left a bit dazed and determined to go into the shift the next day with an open mind.
My first shift was on the ENT (ear, nose, throat) ward, that changed to dermatology when I arrived. I was then told by my buddy student nurse that it was an overflow medical ward, and the first case I dealt with was paediatrics. Basically it was the bit of everything ward.
The first thing that struck me was the lack of formal handover, staff came and went but no one seemed to know what was happening with each patient. The teamwork is amazing with all the staff helping change the beds from the nurse in charge to the students and helped me realise how well team nursing works in Australia too. Watched quite a few dressing changes, and was struck by how the knowledge of sterile procedures is there, they have reusable packs, sterile gloves and attempt to maintain a sterile field, the lack of awareness of WHY they are doing something means it's often broken. For example, there was some blood on the floor which the nurse wiped up with gauze then put back into the sterile field, before asking me to get the gauze because she couldn't touch the canister. To clean and sterilise equipment such as kidney dishes it's dropped in a massive bucket of bleach. Everything is reused, including gauze and EVERYTHING is dressed with bedatine, gauze and tape.
This lack of understanding why and the possible consequences of what they're doing came up again and again. My second shift in emergency saw a patient being given morphine and when asked the administering nurse had no idea about the side effects and dangers of the drug. At the end of the first shift, we were all struck by how resourceful they are, doing so much with the minimal resources they had. Catheters are used as tourqinets And the plastic wrapper off gloves as emesis bags.
However as we learnt more, we realised that the resources are there. It might not be new and flash but they do have access to what they need. It's the education that's lacking. There is a very strict hierarchy in the hospital of surgeon knowing the best, doctor next best and nurse the least. This means that nursing assessments are non-existent because 'the doctor will do that' and no one wants to step over that line. It's slowly changing but the concept of a COLDSPA pain assessment or questioning the characteristics of chest pain was so foreign.
On that note, one of the most disturbing things we all found was the lack of pain relief administered. It's a widespread belief that it's addictive and that pain is an emotional experience that is non existent if you are properly psychologically supported. This saw post-op patients on no pain relief, nothing given in emergency and knees being relocated without anything. It's is believed that the surgeon knows exactly what pain will be experienced and will write up the right drug, however patients are clearly in excruciating pain, and maybe given only voltarin once daily.
It is interesting to learn how Bhutanese culture and Buddhism is so ingrained into health delivery. One diabetic elderly patient with a leg wound so extensive and necrotic I had to leave the room (and I've got a stomach of steel) refuses to have it amputated despite the fact it will never heal and she's in excruciating pain. On questioning we realised that she believed that should she lose her limb, she'll be disabled in her next life. Among others this case increased my awareness on how we can't push our beliefs on others in the absence of full knowledge and understanding.
Reading back over the last bit I've written it sounds so misleadingly negative. It's not all bad, it's a new and developing system and workforce and they are moving in the right direction. Our student buddy nurses from RIHS were absolutely incredible, both in going out of their way to help and show us and make sure we were ok and also in their scope of practice. 2nd year students were performing skills so advanced, such as cannulation and taking blood from a newborn it was impressive. With such a HR shortage, their skills are needed to ensure the running of the hospital. It was the lack of knowledge behind what they were doing and the background of their patients that shocked me. They are taught assessment and pathophysiology at RIHS but with no support in the hospital and a system that degrades nurses knowledge, they are unable to put it into practice.
In the next couple of days we're heading out to satellite clinics and conducting heath assessments at the local Chorton. Cannot wait to get as much out of it as I can and again an even greater understanding of an amazingly varied, new and constantly developing healthcare system. If never been so sure this is what I'm meant to do, or been so inspired to put the knowledge I'm privileged to have into practice.