Dakota Nurse: Making a Difference Around the World

Currently employed as an Air Force officer in the Nurse Corps, Lt Col Bassett was born and raised in Belle Fourche, S.D.  She received her B.A. in Nursing from Augustana College in 1976 and her M.S. in Nursing from SDSU in 1985.  After joining the Air Force in 1991, Lt Col Bassett has been stationed throughout the U.S. and overseas, however nothing ever compared, she says, with her current experiences while forward deployed in Afghanistan.

Why is the U.S. sending troops to teach Afghan nurses?
The answer to this has to do with counterinsurgency warfare/tactics.  More specifically, U.S. troops do many forms of mentoring throughout the fledgling Afghan National Army (ANA) so that they can be successful in defending the country and its legitimate, democratically-elected central government.  If the ANA fails the government is in serious danger of a coup, failure and extension of Taliban insurgency influence. 

A small piece of the overall ANA plan is to help them stand up a military medical service--patterned after our own.  The Afghan nurses and doctors are all officers in the ANA.  They treat ANA soldiers and their families, Afghan National Police (since they have a less developed system, but are targeted by the Taliban fighters the same as the soldiers) and Afghan civilians, on a humanitarian basis only.

Who do you work with?

My assignment is to mentor (advise) the ANA chief nurse and oversee the care that 30 ANA nurses/officers deliver within the 50-bed Kandahar Regional Military Hospital.  The 30 nurses are all men, however there are a few female nurses within the ANA Nurse Corps at large.  As the only nurse on our mentoring team, this is keeping me very, very busy.

How is nursing care delivered?

Due to security issues in southern Afghanistan, we cannot travel outside our base to observe Afghan culture or do humanitarian missions.  Statistics show, however, 155 babies die for every 1,000 live births (U.S. rate is 6.9:1,000); there is a one in eight lifetime risk of maternal death (compared to 1:4,800 in U.S.).  Hygiene is very poor, with 70 percent of people residing in rural regions lacking safe drinking water.  Homes in Kandahar City have approximately two hours of electricity per day—and with summer temperatures soaring to 130º, life really becomes difficult.

Within the ANA hospital, built by the Army Corps of Engineers and opened in Jan. 2008, the Afghan military nurses deliver care which I would say is comparable to the 1950s in the U.S.  They use a functional style of care, ie., one procedure nurse, one dressing (wound care) nurse, one transport nurse.  Housekeepers clean patients and linens as well as floors and bathrooms.

Medications (PO/IM/IV) are all delivered to the patient’s bedside twice per week after the doctors make their rounds and write orders.  Most patients are illiterate (even the soldiers) so slashes are written on the back of packages to tell the patients how many times each day to take their medication.  Nurses make rounds several times per day to reconstitute and inject (IV Push) any IV medications which were ordered.

Nurses are eager to learn to use the new machines and technology we give them, but basic understanding of human physiology and assessment of patient condition is mostly left to the doctors.  Documentation is nearly absent; a simple Medication Administration Record (MAR) has recently been instituted, but the day shift procedure nurse signs off all the medications given to each patient over the past 24 hours.  Many of the nurses, while literate, have not chosen to read/write since their school days.

On the other hand, the patient care need is massive.  Our small (50-bed) hospital sees two to three MASCALs per week with polytrauma injuries from gunshot wounds, rocket-propelled grenade attacks, improvised explosive device blasts and suicide bombings.  Many multiple fractures, burns, massive internal damage and amputations result.  Lt Col Bassett writes, “I originally thought I had a small-town type hospital to oversee, until I looked around one day and saw nine recent amputees and four patients with chest tubes.”

What is the nurse training like?

Young Afghan students are tested when they graduate from high school.  If they score very high they are eligible to attend medical school.  Those scoring not as high are eligible for engineering, pharmacy or similar type colleges.  Those scoring lower are shepherded into a general “medical” (really nursing) education.  That school, I am told, is nine months long.  It does not include anatomy/physiology or information about diseases--that is for doctors.  Likewise, it does not include any hands-on practice in a hospital.  Students learn how to do procedures that a doctor may require, e.g., starting IVs, obtaining an EKG, performing wound care etc.  They are very, very good at procedures.

Many of the ANA military nurses have been given opportunities for additional training later, usually in Iran, Pakistan or India.  However, being a nurse is not something to be proud of in Afghanistan.  They will not use a medication cart because they are ashamed to be identified as a nurse (instead of a doctor).  Thus, many nurses go on to “higher” training as lab techs, x-ray techs, pharmacy techs, dentists or OR techs. 

How do you teach them U.S. techniques and ways when they have different procedures/resources? <br>As one always should, I started by getting to know the nurses and their abilities and trying to understand the care they have been providing (quite proudly) for hundreds of years.  Then, I chipped away at the procedures that truly may endanger the patients’ health, or at the very least not be helpful.  An example would be when I arrived here I found NO documentation except for the doctor’s orders.  The nurses could not understand why they should write anything more when it was obvious that the doctor had written it once already and that was what the nurse gave.  I am happy to relate that I have convinced the nurses to document vital signs for the doctor’s review and they are currently becoming proficient with intake and output records.

But, that example also brings to light an ethical dilemma.  Who says they have to do things in a U.S. manner or use U.S. techniques?  There are many ethical questions like this to be considered as a mentor.

What is your relationship with the nurses like?

My relationship with the 30 nurses at this hospital is quite unique and special.  Being a female adds to the uniqueness (all male nurses, only two female “servants” in the hospital).  But honestly, being over 50 years old and still active--without a cane (when their average lifespan is 44 years) is awe-inspiring to them.  They bring me chai tea about four times a day and insist I rest frequently.  However, when we have mass casualties, and we have small MASCALS every three to four days with nearly 90 episodes of polytrauma patients so far this year, we all just become nurses working together, doing whatever it is we have to do to save lives.

What are some success stories you have?

I am proud that the nurses now consistently check vital signs on emergent patients in the ER.  I am also proud that they see the need to write down how much Morphine they give and when.  I am pleased that housekeepers have recently started putting SOAP into the floor scrubber.  I am ecstatic that nurses and patients alike have learned how to brush their teeth (yes, I literally had to do demonstrations).  I feel good that patients with amputations are now allowed to get into wheelchairs and interact somewhat normally with other soldiers in the parking lot.  And lastly, I am happy that they have had a glimpse of Americans who truly care about them and their overwhelming problems in daily life.

What can be done to enhance professional nursing?

Certainly, major changes must take place in Afghan nursing schools and the primary/secondary education given to aspiring nurses.  In much of the country women are beginning to join the ranks of workplace contributors.  Changing existent systems is difficult and slow.  Social and religious customs strongly influence this part of the world.  Additionally, as my chief nurse mentee, Captain Niaz, tells me, “If I demand too strongly that my nurses change things, they will meet me on the street and shoot me dead.”  That is reality here. 

At our hospital, we have started an ambitious program of 36-modules of basic nursing education.  These men’s attention to detail is short, so the modules are made of 10-12 slides of mostly pictures and are made to be presented in 20 minutes or less.  We cover topics such as “Pulse, what is it and what do fast/slow pulses mean” to bolster basic assessment skills.  Other modules address specific equipment such as IV pressure bags or fluid warmers.  My favorite modules introduce the Afghan nurses to “new” concepts such as unit dose or I&O flowsheets.

We also bolster the nursing profession with events of honor.  I was very fortunate last spring to take 28 ANA nurses to a celebration where we joined with 100 nurses from 10 different coalition nations to celebrate Nurses Day--the first time these Afghan nurses had ever felt included with the rest of the world’s nurses!

Reference: World Health Organization, http://www.who.int/reproductive-health/publications/maternal_mortality_ 2005/mme_2005.pdf