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Introduction of Rehabilitation Nursing Concepts in Cambodia

Cambodia is a poor country in Southeast Asia; 80% of its 14.1 million people are sustenance farmers (Central Intelligence Agency, 2006). Health Volunteers Overseas, based in Washington, DC, and Sihanouk Hospital of Hope in Phnom Penh, Cambodia, collaborate to recruit master’s-prepared nurse educators to participate in volunteer teaching trips to enhance the knowledge and skill set of Cambodian staff nurses. A methodical series of steps were taken to develop a basic lecture series regarding the care of patients with brain and spinal cord injuries, taking into consideration Cambodian healthcare beliefs and health system resources. This article describes the processes used to develop the lectures and the realities of teaching on the other side of the world.

Cambodia is a country that continues to suffer from decades of war and civil unrest. In 1975 the Vietnam War came to end. Pol Pot seized this opportunity to overrun Cambodia with his Khmer Rouge forces with the intention of establishing a Maoist type of agrarian society. Pol Pot directed the people of Cambodia to act “as oxen, obedient and without independent thought” (Szymusiak, 1999). Key to meeting his goal was the destruction of the healthcare and education systems, as well as the elimination of educated individuals. Even the possession of eye glasses was enough to warrant a death sentence. More than 1.7 million men, women, and children were murdered during the 4-year period of Pol Pot’s horrific attempt to create his vision of utopia. Fewer than 40 doctors were known to have survived the killing fields, and no records are available to identify the number of nurses who were killed (Santini, 2002).

Fast forward to today. Cambodia is a poor country in Southeast Asia; 80% of its 14.1 million people survive as sustenance farmers (Central Intelligence Agency [CIA], 2006). The majority of Cambodia’s citizens (84%) live in rural areas, and only 16% of the population lives in urban areas. The World Health Organization (WHO, 2007) reports that the probability for Cambodian men to die between the ages of 15 and 60 years is 429 per 1,000 population and the probability for Cambodian women in the same age bracket is 297 per 1,000 population. The healthy life expectancy at birth for men is 46 years and 49 years for women. This places Cambodia as 174th among the 190 nations ranked by the WHO (WHO).

Cambodia developed its first health strategic plan (HSP) for 2003–2007 in 2002. The HSP outlines a framework to guide both governmental and nongovernmental agencies in the creation and implementation of strategies to strengthen health services and improve health outcomes (Kingdom of Cambodia, Ministry of Health, 2002). Action steps call for the “provision of affordable, essential specialized hospital services” and “capacity development within the health system” (Kingdom of Cambodia, Ministry of health, p. 2). This call to action creates opportunities for nursing knowledge and practice to be introduced from industrialized nations to Cambodia. After a prior visit to Cambodia, during which I was exposed to the harsh reality of Cambodian living and healthcare conditions, I was driven to return there to use my skills as an educator to contribute to the rehabilitation knowledge base and practice of Cambodian nurses.

The first step toward achieving my goal was to identify an organization to help establish an introduction to a Cambodian hospital. Health Volunteers Overseas (HVO; 2006) recruits experienced, master’s-prepared nurses with teaching experience from the United States to provide continuing education programs to staff nurses of Sihanouk Hospital of Hope in Phnom Penh, Cambodia. This collaborative effort with the Sihanouk Hospital of Hope is designed to raise the level of Cambodian nursing practice and understanding. Specific nursing outcomes that have been produced from this endeavor include

  1. Cambodian charge nurses becoming more autonomous in clinical management, allowing a decrease in expatriate clinical coverage
  2. Raising the level of Cambodian nursing leadership training
  3. Establishing a relationship with HVO that will provide specialized nursing training in the years ahead.

HVO has not had a nursing educator certified in rehabilitation nursing conduct programming at the Sihanouk Hospital of Hope since the inception of the relationship. An application was made to become an HVO volunteer; after the application process was completed, the director of nursing from the Sihanouk Hospital of hope offered a 2-week volunteer teaching engagement. A project plan was then created to promote the success of the venture and included

  • he development of planning questions from which the lecture material could be framed
  • he solicitation of professional colleagues to participate on formative and summative committees for topic development and evaluation of proposed lesson plans
  • focus group of local rehabilitation nurses with English as a second language to assess lecture content and develop teaching strategies.


First, it was assumed that the program topics collected from the nurse educator at Sihanouk Hospital Hope were based on an internal self-assessment and the request for topics accurately reflected the rehabilitation education needs of the nursing staff. A second assumption was that the nurses at Sihanouk Hospital of Hope had a basic competency in nursing practice upon which a rehabilitative nursing skill set could be built. Finally, it was assumed that the nurses at Sihanouk Hospital of Hope had prior exposure to traumatic brain injuries (TBIs) and spinal cord injuries (SCIs).


There were several limitations in this project. First, the English-speaking and comprehension abilities of the nurses at Sihanouk Hospital of Hope were limited. Also, the Cambodian nurses did not have access to the same equipment and materials—in quantity and type—that are currently available in U.S. rehabilitation hospitals. Therefore, both the formative and summative committees had to take these challenges into consideration when assessing lecture content.

Planning Questions

The next step in setting up the program was to identify planning questions that would help frame the rehabilitation nursing subject matter to be presented. Questions such as “What are the main causes of injury in Cambodia?” and “What are Cambodian views on health and illness?” were used to help narrow the scope of the lectures.

Causes of Injury

Land mines and road accidents are the most significant causes of traumatic injury and death in peace-time Cambodia. Land mines are particularly serious for children and youth who attempt to salvage unexploded ordinance to sell as scrap metal (United Nations Children’s Fund [UNICEF], 2006; Walsh & Walsh, 2003). Cambodia has one of the largest numbers of people with disabilities in the world. There are an estimated 40,000 survivors of land mine explosions or unexploded ordinance, with 800 more new land mine injuries occurring annually (Landmine Monitor, 2006).

Traffic fatalities have become the second-leading cause of death in Cambodia, second only to HIV/AIDS (Integrated Regional Information Networks [IRIN], 2008). The number of traffic fatalities has doubled during the past 5 years to 4.2 deaths per day in 2007 (IRN). A contributing factor to this uptick in fatalities is the number of people moving from the rural countryside to the city. These new urbanites possess a limited knowledge of road safety. Motorcycle drivers are now required to wear a helmet; however, passengers are not and 70% of Cambodia’s road traffic injuries are associated with motorcycle riders and nearly 40% of them suffer from head injuries (Department of Planning and Health Information, 2006; Ministry of Public Words and Transport, Ministry of Interior, National Road Safety committee, and the Global Road Safety Partnership, n.d.). The resources to care for the resulting multitrauma, traumatic SCIs, and TBIs are currently limited because affordable, accessible health care and healthcare professionals who have received the necessary education to care for these patients are lacking (Damme, Lemmput, Por, Hardeman, & Meessen, 2004; Lanjouw, Macrae, & Swi, 1999).

Cambodian Views on Health and Illness

Cambodians are not uncomfortable with Western medicine but they often rely on traditional measures practiced at home before seeking medical care, or they use the traditional methods in conjunction with Western medicine (Baylor University, n.d.). The Khmer view illness as an imbalance in natural forces, which is also known as the humoral philosophy. The Khmer’s participation in health care is oriented to the symptoms; when symptoms are gone, treatment is no longer required (Cross Cultural Health Care Program, 1996). The Khmer’s participation in preventative healthcare strategies is limited (Baylor University), creating challenges for completing daily activities that minimize the risk of complications associated with SCIs, such as bowel and bladder programs, weight shifting, and skin inspection. In addition, the Khmer believe that spirits affect illness, which can complicate a patient’s and his or her family’s understanding of the care required for individuals with TBIs (Baylor University). Rather than viewing a person as having a brain injury, he or she may be viewed as spirit possessed. Understanding these cultural viewpoints helped create the lens through which the learning materials for this project were developed and evaluated for appropriateness and usefulness.

Formative and Summative Committees

A formative committee was recruited to identify the rehabilitation subject matter needed in Cambodia to develop effective rehabilitation nursing skills. The committee also reviewed a sampling of lecture outlines to ensure evidence-based clinical practice methods were used. A summative committee was also formed and given the assignment of examining lecture content for cultural clarity, appropriate level of complexity, and appropriate presentation. Cultural clarity, for the purpose of this article, is defined as the presentation of information by an instructor of one culture to an audience of another culture with the audience possessing various degrees of English comprehension. Educational programs and teaching strategies that are effective in one country cannot simply be replicated in other geographic regions without considering other factors (Conway, Little, & McMillan, 2002). “Culturally congruent” education is education that is “provided in a manner that is meaningful and useful” (Crane, 2006). Nursing education must keep in mind the local cultural, religious, economic, social, environmental, and political influences (Allen & Ogilvie, 2004; Murray, 2005).

Two members of the formative committee were nurse educators who had each spent 2 weeks at Sihanouk Hospital of Hope (through HVO) teaching the nurses about their respective specialty subjects. The third member of the formative committee was the nursing education director at Sihanouk Hospital of Hope. The formative committee communicated frequently via e-mail to define the scope of rehabilitation nursing practice to be presented and to refine the lecture content. The formative committee members, who were former HVO volunteers, also examined PowerPoint presentations and provided feedback about whether the material could be successfully communicated to the Cambodian audience.

The selection and role of the summative committee members were critical. All four members of the committee were doctoral-level professionals and were well-versed in the challenges of providing health care in diverse cultural settings. One of the committee members was assigned to the author through HVO as a professional advisor for the trip. It was this committee member’s well-established relationship with Sihanouk Hospital of Hope, as well as her background in academics and as the author of a rehabilitation nursing textbook, that proved to be invaluable in the development of the lecture series. Each member was assigned a PowerPoint presentation to review and evaluate.

Lecture Development

The healthcare needs of the Cambodian population are tremendous, and the scope of the project was driven by the Sihanouk Hospital of Hope nursing education director’s specific request. The nurses of the hospital had not been exposed to the concepts of rehabilitation nursing. It was the education nursing director’s wish that the program’s material concentrate on the care of patients with traumatic SCIs and TBIs, using lecture materials and direct patient-care modeling on the unit. Although Cambodia does not report the levels of TBIs and SCIs, the nursing education director specifically requested we cover these topics, citing road accidents, land mines, and unexploded ordinance as significant sources of injury in Cambodia (which was subsequently supported by a literature review).

The nursing education director also requested that the author participate in the journal club that was held twice a week at the hospital. It was left to the author to choose the journal topic; it did not have to be specific to rehabilitation nursing. The journal club was held during lunch time and had an average attendance of 8–10 nurses. The journal club included discussions about the types of brain injuries and caring for patients with brain injuries and in skeletal traction. In this small group setting, questions and discussions about the role of nurses as critical thinkers who help guide their patients across the illness-wellness continuum were encouraged. In addition, the club also talked about how assessment, prediction, and interventions are all critical components of the nursing milieu.

Post-trip reports (provided by former HVO volunteers who had taught at Sihanouk Hospital of Hope) contained expressions of regret that lecture was the only format used to present information. They believed a more interactive method of learning would have improved comprehension and value. One nurse posted, “They were not unlike our own nurses who attend a program right after working. I saw eyes begin to droop after a couple of hours.” Therefore, a variety of teaching methods were used to infuse energy and a bit of team building into the presentation of materials. Teaching methods included worksheets and colored pencils; teamwork to develop nursing care plans and answer case study questions; and games, such as Jeopardy, to encourage learning and promote active interaction. Donors provided pen lights, ink pens, clips, tote bags, and candy for prizes and gifts.

A group of foreign-born nurses who work locally in rehabilitation nursing and are acquaintances of the author were asked to provide feedback on the planned teaching strategies to enhance comprehension of the material. All of these nurses were well-versed in the author’s teaching style because the author was the staff educator at their institution. Collectively, the nurses believed the greatest challenge would not be the lecture material content or any necessary modifications to the material due to classroom limitations or resources. They believed the greatest challenge would be the actual delivery of the material. It was with no small amount of humor that they shared, “those nurses will simply not know what hit them. You must slow down and keep your enthusiasm in check.” Despite this, the nurses also felt that the author possessed the ability to be effective and the experience would be meaningful.

The Reality

During 2 weeks in March 2007, the rehabilitation nursing lecture series was presented to the staff nurses of Sihanouk Hospital of Hope in Phnom Penh, Cambodia. There were three challenges that affected the delivery of the material and, more importantly, how the material was assimilated into Cambodian nursing practice. The first challenge was learning that the nursing staff Sihanouk Hospital of Hope had never seen an SCI and that their experience with brain injuries was very limited. When asked why this particular content was in such high demand, the response was, “we need to know everything and prepare ourselves.” The second challenge was learning that Cambodian nurses do not provide personal care or patient and family education. Patients in Cambodia receive food from their families; their families also assist with transfers, toileting, feeding, and bathing—not the nurses. The volunteer experience was only 2 weeks, which made it difficult to accomplish any effective transference of rehabilitative nursing concepts from the classroom to the bedside. The third challenge, which emerged during the first presentation, was the author’s teaching style. Despite best intentions, enthusiasm and energy quickly outpaced the rate of English comprehension, overwhelming the Cambodian nurses. However, the problem was promptly recognized and the audience was given the authority to ask for a pace change at any time by simply raising a colored piece of paper. Fortunately, this was rarely required after the first lecture.

Programs were offered not only to the day shift nurses but to the night shift nurses as well. This was the first time the hospital staff had extended this opportunity. Speakers’ energy levels were taxed on the days when lectures were presented four to five times; however, it was worth the investment. Night shift nurses were appreciative for the opportunity and provided positive feedback about the experience. It also presented the author with a chance to observe the off-hours operations of the hospital.

During the 2-week program, the nursing staff enthusiastically enjoyed the tactile learning experiences, such as matching the lobes of the brain with the symptoms presented when damage to that lobe occurs and using coloring worksheets covering the central nervous system and anatomy of neurons. The personal investment of self—through daily rounding, learning about the individual nurses, sharing pictures and stories of home, and attempting to learn and use Cambodian words—all helped bridge the cultural divide and make the experience rewarding.

Implications for Practice

The implications of this project are long lasting and have the potential to affect nursing practice on both sides of the globe. Current research and literature support the sharing of health information and resources with developing countries, as long as the sustainable plan of action respects the cultural environment. Opportunities and implications for practice include, but are not limited to

  • orking with the hospital nursing administration to help establish quality indicators for performance that will promote positive health outcomes for the population; examples include utilization of pressure ulcer tools and use of patient and family discharge education materials
  • ssisting the nurse educator in assessing and analyzing patient data and nurses’ knowledge to develop future continuing education programs
  • sing distance learning methods and onsite delivery to foster long-term collaboration between rehabilitation nurses in industrialized nations and Cambodian nurses.


It is rare that an individual has the opportunity to participate in the reinvigoration of a country. Although Cambodia was brought to its knees by modern warfare, it remains rich in cultural and intellectual history and teems with energy. This country has the potential to emerge from a dark time stronger and more resilient—a mix of the old and the new. As stated by the former United Nations (UN) Secretary-General Kofi Annan, “Success will require sustained action … It takes time to train the teachers, nurses, and engineers to build the road, schools, and hospitals; to grow the small and large businesses able to create the jobs and income needed. So we must start now. Nothing less will help” (UN, 2005). The collaborative effort of the Sihanhouk Hospital of Hope and HVO is a long-term commitment to improving the health care of Cambodia.

About the Author

Karen S. Reed, MSN DHSc RN CNL CRRN, is a clinical assistant professor of nursing at the University of Florida, College of Nursing in Gainesville, FL. Address correspondence to her at ksreed@ufl.edu.


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