Three times a year, charity Transform Healthcare Cambodia takes groups of nurses, students and other UK health professionals to the South East Asian country to work with local health staff and provide training and advice.
“It is quite life-changing for some of the nurses that come out”
The charity also provides opportunities for healthcare professionals from Cambodia to come to England on study tours and see NHS services in action.
Sue Smith, chief nurse and deputy chief executive of Morecambe Bay University Hospitals, is one of the charity’s directors and founders.
She admitted it was often a bit of a “culture shock” for UK health workers when they first visited the country, where millions were killed by the Khmer Rouge during the 1970s under a brutal regime that saw clinicians murdered and the healthcare system destroyed.
The charity was established in 2013 and mainly works in Battambang Province. Over the years, it has supported services to put in place basic systems and processes including life support, patient safety and infection control.
Ms Smith, who was awarded an OBE last year, said the initiative made a “massive difference” not only to healthcare staff in Cambodia but also to nurses and others who go out to help.
“They gain skills and confidence,” she said. “It is quite life-changing for some of the nurses that come out.
“When you haven’t got all the medication and resources we have got, you have to deal with things in a different way. They start to become a lot more rounded in the way they look at problems when they come back to England.”
Nurses who take part in the scheme are also encouraged to draw on their experiences working Cambodia as part of revalidation. “The skills they pick up doing this are unlike anything you will ever get in England and adds value to a nurse’s portfolio and skillset,” said Ms Smith.
She travels to Cambodia herself at least once every two years, finding it hugely rewarding to see services continue to develop.
“You feel like you are making a difference in a big way because you can see the improvements year on year,” she said. “You never stop learning and this keeps me humble and very grounded. It is one of the most significantly satisfying things that I do.”
Key issues Cambodian colleagues are keen to tackle include ways to improve the care of people with alcohol and mental health problems – often linked to the nation’s recent traumatic past. Stroke and dementia are other priorities now the country is “getting an older population for the first time” in living memory.
“You feel like you are making a difference in a big way because you can see the improvements year on year”
While much of the charity’s work centres on Battambang Provincial Hospital, it has also been working with community clinics and GP surgeries.
As well as providing practical support, the close working relationship between the charity and Cambodian colleagues has enabled the UK team to influence practice in other ways, for example on equality.
“For me, a really big moment was when I saw that women in the hospital – female doctors and female nurses – are all seen as equal partners,” said Ms Smith. “The first time I went, there were no women around the board table when we had meetings – now it is equal and that is fantastic.”
Nurses and students who take part are asked to fund their own air fares and accommodation. However, interest is high, with more than 100 applications for 20 places in the latest cohort.
Those who travelled to Cambodia in November last year included Catherine Randall, deputy head of safeguarding within NHS England’s nursing directorate, who described it as “one of the most valuable, life-changing experiences” she had ever had.
Together with two colleagues, she was tasked with looking at safety and quality at Battambang Provincial Hospital. But when they arrived some of their plans went out of the window.
“We went out with lots of grand ideas about key performance indicators and quality markers but when we landed we quickly realised we needed to be far more basic – we needed to listen, observe and experience what it was like to be a nurse in a developing country, where there is deprivation and poverty,” said Ms Randall.
“What struck me was that nobody washed their hands”
Having spoken to senior nurses at the hospital, they realised sepsis and infection were major problems, leading them to do further research and observation on the wards.
“What struck me was that nobody washed their hands,” said Ms Randall. “Patients didn’t wash their hands, families caring for patients and loved ones didn’t wash their hands, nurses to nurses, nurses to doctors, doctors to nurses, nurses to patients, patients to nurses – nobody washed their hands.”
Facilities for hand-washing were basic and some wards had no hand-washing facilities at all, so the UK team agreed a plan with Cambodian colleagues to teach basic hand-washing technique.
“We divided into teams and facilitated hand-washing demonstrations in the ward, in staff areas, on corridors, outside – wherever we could – alongside the senior nurses, because they needed to lead by example,” she said. “We ended up teaching about 500 doctors, nurses, patients and family members over the next two days.
People were tapping us on the shoulder saying: ‘teach us – tell us how to wash our hands in a good way’. We’d see them in the corridor the day after and they would show us the seven steps of hand-washing.”
The team also helped introduce new systems, including appointing safety champions to continue regular hand-washing training and ensure hand sanitisers were filled twice a day.
“It was amazing to know that our training and empowerment has made a difference at the simplest of levels”
Another team who went out three months later reported these measures were still in place, with soap dispensers and hand sanitisers full and in use and staff practising good hand-washing technique.
“It was amazing to know that our training and empowerment has made a difference at the simplest of levels,” said Ms Randall. “If we stop one person from getting sepsis or dying from a chest infection that would be absolutely incredible.”
Ms Randall, who has a background in midwifery, health visiting and public health nursing, said the experience had been a real eye-opener. One of her lasting memories was her first day at the hospital when she spent a couple of hours working alongside midwives to make sanitary towels out of cotton wool and gauze.
She said: “If somebody had told me I was going off to Cambodia to make sanitary towels, I would have gone: ‘don’t be daft – why don’t we just buy them in?’. It made me recognise how much we as professionals waste – I felt very proud of every sanitary towel I made.
”At one stage, one of midwives took one off me because I had got my corners wrong, which just shows you can never have too many years under your belt to be taught something new.”
She said the experience had taught her that “the simplest things can make the biggest difference”. “As a practitioner, I made a difference in another country with nothing apart from being me,” she said. “It reminded me that we are the most important commodity in the NHS.
”We are quick to complain about resources and not having this and that, but Cambodia taught me you can do the most amazing things with nothing.”
Louise Johnson, general manager for urgent and emergency care at North Tees and Hartlepool Foundation Trust, was also part of the team who went to Cambodia in autumn last year and said it had been a “powerful” experience.
“When I got there, it was a bit of a shellshock because it was pretty far removed from anything I have previously experienced within a healthcare setting or life in general,” she said, citing the fact patients may sleep on beds without mattresses while families often sleep on mats on the floor.
“It is a stark contrast,” said Ms Johnson, who trained in both adult and children’s nursing. “Families care for the children while they are in hospital and people sleep on whatever they sleep on at home. Many come from farming communities who don’t sleep on beds. It was the first time I had experienced anything like that but after a few hours it just became the norm.”
“It was a bit of a shellshock because it was pretty far removed from anything I have previously experienced”
Before she moved into her current management role, she was an accident and emergency sister for 10 years and admitted she missed the regular “direct clinical contact” with patients.
“I don’t have that as much now in my current role, so that was one of the things that attracted me [to the scheme] – doing something meaningful in direct contact with patients and members of clinical teams,” she said.
Once in Cambodia, she worked closely with a paediatric registrar and charity trustee, Daisy Taylor, to look at ways they could support clinical teams on the hospital’s children’s ward, which also cares for newborn babies. This included running training sessions on specific areas such as treating children with a respiratory illness.
“On a morning, we would generally join the ward round with the consultant and the nursing teams and then interact with the children and staff,” she explained.
“Daisy would help to support some of the decision-making and perhaps give some advice on some of the presentations and treatment of the children, and we’d use the information we were getting about practice to tailor teaching sessions in the afternoon.”
“The focus is on basic management and trying to prevent deterioration”
Ms Johnson said part of the challenge was working with the limited resources available.
“They have got the skills, knowledge, experience and an absolute desire to do the right thing and look after children,” she said. “What they haven’t necessarily got is all the tools to do that, especially when it comes to more advanced levels of care such as airway management and intubating children, particularly newborns. The focus is on basic management and trying to prevent deterioration, which is very much what we were teaching them.”
One piece of work they did was to help set up a triage trolley. “We had noticed was there was equipment everywhere. Some of it was very limited but there didn’t seem to be a structured approach to the equipment they did have,” she said.
“They had a lovely area for children who arrived from A&E or one of the community hospitals but then they would be scrabbling around for kit such as oxygen masks, so we set about introducing a more systematic approach.”
They also encouraged staff to make better use of a display board for staff to provide up to date information about the children in their care, such as whether or not they had been seen by a consultant.
“By the end of the week, we were coming in of a morning and the board was up to date and they were using it as a focal point for handovers which they hadn’t been doing previously,” she said.
“It certainly made me appreciate my job, the place I work, my family”
As a nurse, she said she had learnt some valuable lessons about the most effective way to shape the practice of others. “It teaches you to think more about the impact you have on others and how you can influence things without going in and telling people what to do,” she said.
“This was about harnessing their desire to provide good care in a way that was helpful to them and what they needed – rather than what you might think they need.”
Overall, she said the experience gave her “a lot of insight and a lot of perspective” – something she has been keen to share with colleagues back home.
“It certainly made me appreciate my job, the place I work, my family,” she said. “It helped me do a stocktake of my life and everything I have got and the fabulous healthcare system we have that we take for granted every day.”
Transform Healthcare Cambodia
Transform Healthcare Cambodia
Transform Healthcare Cambodia