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Letter to the Editor

Development and Implementation of Cornerstone Documents to Support Nursing Practice in Cambodia

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Richard Henker, PhD, RN, CRNA, FAAN
Manila Prak, RN, BSN
Virya Koy, RN, SNA, MNSc, MHPEd

Abstract

Cornerstone, or guiding documents, for nursing and healthcare support the profession of nursing throughout the world. This article describes the impact of the civil war and instability in Cambodia that led to poverty and destruction of the healthcare system and provides a brief overview of nursing in Cambodia today. Since the 1990s, the Cambodian healthcare system has been recovering from war. Nurses have been transitioning from task oriented roles to more sophisticated roles that incorporate the nursing process. In addition to significant changes in nursing education and other advances in the healthcare system during the last five years, the Ministry of Health (MoH) has strongly encouraged the development of cornerstone documents to guide nursing practice for patient care provided in Cambodia. Standards and competencies have been developed based on the American Nurses Association (ANA) template for Scope and Standards of Practice. Cornerstone documents for nursing that have been implemented by the MoH, many at the Angkor Hospital for Children, include evidence based protocols, the nursing process framework, the Code of Ethics for Nurses and development of the Scope of Practice and Standards of Care for Cambodian Nurses.

Citation: Henker, R., Prak, M., Koy, V., (May 31, 2015) "Development and Implementation of Cornerstone Documents to Support Nursing Practice in Cambodia" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 2, Manuscript 5.

DOI: 10.3912/OJIN.Vol20No02Man05

Key words: Scope of practice, code of ethics, standards of care, Low income, Cambodia, nursing, cornerstone documents

Nursing in Cambodia is transitioning from a task oriented role to a professional position that incorporates more critical thinking. Nursing in Cambodia is transitioning from a task oriented role to a professional position that incorporates more critical thinking. Progress in the nursing profession in Cambodia has been associated with policy development at the Ministry of Health (MoH) that has included the implementation of evidence based protocols, introduction of the nursing process framework in 2004, implementation of the Code of Ethics for Nurses in 2013, and finalization of the Scope of Practice and Standards of Care for Cambodian Nurses in 2014 (see Table 1). This article describes the impact of the civil war and instability in Cambodia and provides a brief overview of nursing in Cambodia. We also review the process of developing and incorporating cornerstone documents in a resource scarce country.

Table 1. Progression of Development of Cornerstone Documents for Nursing in Cambodia

Cornerstone Document

Timeline and Status

Nursing & Midwifery Protocols

Published, 2011

Nursing Process Framework

Introduced, 2004

Approved, 2011

Published, May 2012

Code of Ethics for Nurses

Introduced, 2013

Approved, January 2014

Published, May of 2014

Scope of Practice and Standards of Care for Cambodian Nurses

Translated into Khmer.

Finalized by Ministry of Health, December 2014

Awaiting approval by the MoH, 2015

Healthcare and health indices in Cambodia have improved considerably in the last few years due to the strong economic growth (e.g., Gross Domestic Product growth of 7.3% in 2013) in this low income country (Central Intelligence Agency, 2015). Infant, child, and maternal mortality have improved. For example, maternal mortality has decreased from 320 deaths per 100,000 births in 2005 to 170 deaths per 100,000 births in 2013 (United Nations Statistics Division, 2014). There has also been a decline in the rate of Human Immunodeficiency Virus infection (World Health Organization [WHO], 2009).

Some of the current health-related challenges for the people of Cambodia include an increase in the incidence of road accidents and increased case numbers of infectious diseases, such as enterovirus 71, dengue fever, and malaria (WHO, 2009). Another concern regarding Cambodian healthcare services is the difference in resources available in rural compared to those in urban areas. Eighty percent of the population in Cambodia live in rural areas with lesser resources (Central Intelligence Agency, 2015). The Second Health Strategic Plan, developed by the Cambodian government, focuses on decentralization of healthcare services to decrease the disparity between care provided in urban and rural areas (Cambodia, 2008). Another health-related challenge is the continued recovery from a civil war that led to poverty and destruction of the healthcare system. The next section provides a brief background about the war and its impact on Cambodia to provide context for readers who may be unfamiliar with this history.

The Impact of the Civil War and the Khmer Rouge Regime: A Brief Overview

The evolution of nursing in Cambodia is strongly related to the rebuilding what occurred after tumultuous times in Cambodia from 1970 to 1993. In the early 1970s during the Vietnam War, North Vietnamese forces moved into Cambodia. Fighting by Cambodian troops was supported by the United States (U.S.) government and the U.S. Air Force was involved in bombing of North Vietnamese troops in Cambodia. In 1975, the government in Cambodia collapsed and leadership was assumed by the Khmer Rouge regime, led by Pol Pot.

... during the past five years a significant initiative supported by the MoH has been the development of formal documents to guide nursing practice. The Khmer Rouge implemented reforms in an attempt to develop an agrarian-based, communist society. Cities were evacuated and currency was eliminated. The death of 1.17 to 3.42 million Cambodians occurred during the Khmer Rouge era due to genocide, infectious diseases, and starvation (Heuveline, 1998). Those killed were more likely to be educated individuals (McGrew, 1990). In 1979, the Khmer Rouge lost power and Vietnam invaded Cambodia. After nearly a decade of war time, less than 50 physicians in Cambodia had survived (McGrew, 1990).

During the Vietnamese occupation until the early 1990s, most healthcare was provided by Vietnamese healthcare workers. In 1992, the United Nations was able to start the healing process with the repatriation of refugees and removal of land mines in Cambodia. Although the Cambodian government has worked to increase the number of healthcare providers, the focus has changed to not only increase the number of providers, but to also improve the quality of patient care (Cambodia, 2008). To that end, during the past five years a significant initiative supported by the MoH has been the development of formal documents to guide nursing practice.

Nursing in Cambodia Today

Nursing and Education

There are five nationally supported nursing schools in Cambodia. Four programs provide a diploma degree in nursing and one of five located in Phnom Penh city is providing a Bachelor of Nursing Science (BNS) degree (see Table 2). A small number of private schools in Cambodia have recently developed BNS programs. There are currently only 52 bachelors prepared nurses in the entire country. For the first time in 2014, graduates from nursing programs were required to gain certification by passing a government sponsored exam based on a curriculum developed in conjunction with the MoH (Cambodia, 2008).

Table 2. Nursing Education in Cambodia

Agency Providing Oversight

Government vs. Private
(number of schools)

Location

Ministry of Health

Government Supported Schools of Nursing  (5)

  • Battambang
  • Kampong Cham
  • Kampot
  • Stung Treng
  • Technical School for Medical Care (Phnom Penh)

Ministry of Education

Private Schools of Nursing (8)

  • Chenla Universtity (Phnom Penh)
  • University of Puthisastra (Phnom Penh)
  • International University (Phnom Penh)
  • Norton University (Phnom Penh)
  • Phnom Penh Institute of Nursing and Paramedical Sciences (Phnom Penh)
  • Life University (Sihanoukville)
  • The Asia Institute of Sciences (Phnom Penh)
  • Meancehy University (Banteay Meanchey)

Ministry of Defense

Royal Army Nursing School (1)

  • Phnom Penh

Nursing and Healthcare Facilities

Many of the guidelines for nursing in the MoH were task oriented. There are 80 referral hospitals in Cambodia, with 1,697 health centers for outpatient visits (Cambodia, 2008). Many of the guidelines for nursing in the MoH were task oriented. Although Angkor Hospital for Children (AHC) is a non-government hospital, it has worked with the MoH improve education and develop policies related to nursing and healthcare in Cambodia. The cornerstone documents that have been approved by the MoH were initiated at AHC and disseminated by the External Programs Department at AHC. Below we provide a description of the history and impact (see Table 3) and some of the activities at AHC that have contributed to the development of professional nursing in Cambodia.

Table 3. History and Impact of Angkor Hospital for Children (2015)

History of AHC:

  • Angkor Hospital for Children, a 90 bed, non-government organization (NGO) in Siem Reap, was founded in 1998 to provide care to underserved children of Cambodia.
  • The hospital was started by Kenro Izu a photographer from Japan. While taking pictures of Angkor Wat and surrounding temples for a book, Mr. Izu became concerned about the lack of healthcare for children. He used the profits from his book to develop the foundation, “Friends Without a Border” (FWAB).
  • Initially, FWAB provided most of the support for AHC, but funding now comes from a variety of donors.

Impact on Practice:

  • Angkor Hospital for Children is one of two MoH-designated teaching hospitals in Cambodia.
  • The Nursing Education department at AHC provides a pediatric rotation for all 5 of the government supported nursing schools in Cambodia, and provides continuing education.
  • The Medical Education department at AHC provides a rotation for medical students from the University of Health Science in Phnom Penh, and a postgraduate pediatric residency program.
  • The Capacity Building Program has developed and disseminated cornerstone documents to over 30 hospitals in Cambodia.

Although many initial leadership positions at AHC were held by expatriates, the goal of AHC is to not only provide care to the underserved children of Cambodia, but to educate nurses, physicians, administrators, and other healthcare providers to provide sustainability for AHC. Many volunteers, including nurses from around the world, have provided support for AHC. One of the early executive directors of the hospital was John Morgan, a nurse. Since that time, the perception of nursing at AHC has been very strong and nurses practice to the fullest extent of their education.

Home care teams have seen over 23,000 patients and on average about 800 children are followed by home healthcare. These teams typically include drivers, nurses, social workers, and physical therapists. The teams travel in rural areas to follow and treat patients that do not have transportation to healthcare centers.

In the Outpatient Department at AHC on a typical day, nurses and physicians see approximately 500 patients. If there is a Dengue Fever outbreak, the number increases to 700 per day and a classroom is converted to an inpatient unit. In the outpatient department at AHC, it is typical for nurses to assess, diagnose, and treat patients.

A main focus of patient care at AHC is family education.  In addition to teaching by the nursing staff, television monitors located in many waiting areas of the hospital provide health education content. The strength of the patient care provided at AHC has been noticed by the MoH. Thus even though AHC is a non-government organization, they frequently collaborate with the MoH, the U.S. Agency for International Development (USAID), and the University Research Corporation (URC) on initiatives to improve healthcare in Cambodia.

Development of Cornerstone Documents for Cambodia Nurses

The Nursing Process Framework

The nursing process framework was originally implemented at AHC in 1999. The nursing process framework was originally implemented at AHC in 1999. This guiding framework was disseminated to all nursing schools in Cambodia in 2004 through a program called “Clinical Placement of Nursing Students at AHC.” Although many nurses at AHC have been involved in the advances in care at the hospital, Manila Prak, a nurse educator at AHC, was instrumental in implementing use of the nursing process initially at AHC, and then throughout Cambodia with the support of the MoH. In 2004, after nursing student clinical placements started at AHC, nursing faculty at the 5 public schools of nursing would travel to Siem Reap to learn about the nursing process in an advanced course.

Ms. Prak eventually left the Nursing Education Department to assume the position of director of the External Program Department at AHC. Under her guidance, this department worked with the MoH to improve nursing and medical care provided at provincial hospitals in Cambodia as well as to enhance the nursing profession by working with the Cambodian Nursing Council. Ms. Prak led the development and implementation of the cornerstone documents.

Most projects within the External Program Department at AHC have been supported by the MoH and USAID. This department ultimately evolved into the Capacity Building and Health Education program at AHC. The physician, nurse, and administrative team members of this capacity building team continue to travel to provincial hospitals in Cambodia to provide instruction to clinical staff, implement protocols and procedures, and improve patient care. This effort includes the implementation of the nursing process framework and other cornerstone documents developed at AHC with the MoH.

Code of Ethics for Nurses

In the fall of 2012, nursing leadership in Cambodia moved forward to develop a code of ethics for nurses. In the fall of 2012, nursing leadership in Cambodia moved forward to develop a code of ethics for nurses. The Code of Ethics for Nurses had originally been developed by volunteers working with Manila Prak at AHC. Development of the Code of Ethics for Nurses (Sub-decree Code of Ethics for Cambodian Nurses, 2014) also included discussion with Virya Koy, President of Cambodian Council of Nurses. Ms. Prak worked with Dr. Richard Henker, a professor at the University of Pittsburgh School of Nursing, to develop talking points for the MoH to gain support to incorporate the Code of Ethics for Nurses in Cambodia.

Provisions in the Cambodian Code of Ethics for Nurses are similar to those provided by the ANA (2001) and the International Council of Nurses (2012). The MoH decided to accept and publish the Code of Ethics for Nurses with some revisions in December 2012. In February 2013, the External Program Department staff from AHC, including Ms. Prak, Dr. Henker, and Heidi Donovan from the University of Pittsburgh School of Nursing, developed a workshop provided by the MoH to introduce the Code of Ethics for Nurses to over 40 nurses.  Chief Nurses from many of the provincial hospitals throughout Cambodia attended the workshop. Mr. Virya Koy the President of the Cambodia Council of Nurses and His Excellency Professor Thir Kruy, the Secretary of State of the MoH, presided over the workshop. This workshop was financially and technically supported by the Better Health Services Project funded by USAID (2010) through University Research Corporation (URC).

Scope of Practice and Standards of Care

At the Code of Ethics for Nurses introductory workshop, there was discussion about development of a scope of practice and standards of care document to provide a framework to continue improving nursing care in Cambodia. The Scope of Practice and Standards of Care for Cambodian Nurses (in progress) are based upon a similar document published by the ANA (2010). In August 2013, a draft of the Scope of Practice and Standards of Care for Cambodian Nurses document was developed by the guiding team for the Code of Ethics document (Richard Henker, Manila Prak, and Virya Koy). The document is based on the different levels of practice in Cambodia. Levels of practice include a primary nurse, diploma nurse, and bachelors prepared nurse; the level of education is 6 months, 3 years, and 4 years, respectively.

Competencies for standards reflect current practice (Table 4). After meetings with the Secretary of State, Ministry of Health, H.E. Prof. Thir Kruy, in November 2013 and March 2014, Mr. Virya Koy obtained a grant from the WHO to bring nursing leaders together to work on the scope and standards document.

Table 4. Description of Standards for Practice

Standards of care describe the application of the steps of the nursing process within the practice:

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

Standards of professional performance describe competent professional role behaviors, including activities relating to:

 

  • Ethics
  • Continuing Education
  • Evidence Based Practice and Research
  • Quality of Practice
  • Communication
  • Leadership and Management
  • Resource Utilization
  • Coordination of Care
  • Health Teaching and Health Promotion

...it is anticipated that the scope and standards document will be approved and implemented in 2015. On August 9th 2014, Mr. Virya Koy, President of Cambodian Council of Nurses, presided over a meeting of 28 nurse leaders from Cambodia to work on the Scope of Practice and Standards of Care for Cambodian Nurses document in Siem Reap. The goal at this meeting, funded by WHO, was to identify an appropriate level for the competencies listed in the scope and standards document. Three small groups reviewed competencies for each standard of care for the primary nurse, diploma nurse, and bachelors prepared nurse. Participants then reported recommendations to the larger group. Although the meeting was mostly in Khmer, concerns were translated by Ms. Prak and Mr. Koy and revisions in the document were then made by Richard Henker. The document has been translated to Khmer by Virya Koy. The Scope of Practice and Standards of Care for Cambodian Nurses document was finalized by the MoH in a consultative meeting December 5th 2014. Other government approvals are required, but it is anticipated that the scope and standards document will be approved and implemented in 2015.

Once approved, nursing leaders in Cambodia will continue to determine the impact of this document. For example, a concern voiced during the August meeting was whether or not the scope be included in the regulations for nursing practice?  One of the stakeholders at the meeting was Ms. Kyoko Koto, a master’s prepared nurse supported by Japan International Cooperation Agency (JICA), an organization that promotes the development of low income countries. Ms. Koto’s charge at the MoH is to develop regulations regarding nursing practice for the MoH. Some of the scope of practice language is being considered for the regulations regarding nursing practice. Ms. Koto is also working on incorporating licensure for nurses and other health professionals in Cambodia.

Conclusion

The guiding documents... are modeled after similar publications that underpin the nursing profession in the United States and other developed countries, reflecting their impact on a global level. The tumultuous time in the Cambodia from 1970 to 1993 devastated the healthcare system and its workforce. Since 2004, the Ministry of Health has incorporated policies based on newly developed documents that have included evidence based protocols, the nursing process frameworks, a Code of Ethics for Nurses and a Scope of Practice and Standards of Care. The use of volunteers, staff at AHC, and the MoH, with support from the USAID, URC, and WHO, has led to the development and implementation of these recent cornerstone documents to guide practice. The guiding documents discussed in this article are modeled after similar publications that underpin the nursing profession in the United States and other developed countries, reflecting their impact on a global level.

Additional development of licensure and regulations for healthcare providers is ongoing. The next step in the process to improve healthcare is to expand the evaluation of patient care provided in Cambodia. Cornerstone documents, such as those we have discussed, will improve practice of today and provide a solid foundation to meet these subsequent challenges.

Acknowledgments

Funding and support for this work has been provided by: World Health Organization, Geneva, Switzerland; United States Agency for International Development (USAID); University Research Corporation, Bethesda, MD; Lucy Kelly Faculty Leadership Award from the University of Pittsburgh School of Nursing; American Nurses Association, Silver Spring MD; Health Volunteers Overseas, Washington, DC.

The authors also wish to acknowledge the following contributors to the development of documents discussed herein:

Mr. Koy led the development of the Cambodian Council of Nurses and Cambodian Midwives Council, which was approved by the King of the Kingdom of Cambodia in 2007. He led the group to develop the Code of Ethics for Nurses, which was approved by the Prime Minister in 2014. Mr. Koy also led the working group to develop the Scope of Practice and Standard of Care for Cambodian Nurses. Rick Henker, Manila Prak, and Virya Koy have met with his Excellency Professor Thir Kruy on three occasions to discuss the scope of practice and standards of care.

Professor Thir Kruy, the Secretary of State of the MoH. He was appointed to this position by His Majesty Norodom Sihamoni of the Kingdom of Cambodia. Prior to his work at the MoH, Professor Thir Kruy worked as a pediatrician in an emergency department.

John Morgan, a nurse from the United States, was the executive director of Angkor Hospital for Children from 1998 to 2006, and was instrumental in developing the strong nursing presence critical to the implementation of formal resources to guide nursing practice in Cambodia. Mr. Morgan currently is the Founder and Executive Director of The Lake Clinic – Cambodia.

Heidi Donovan, PhD, RN, Associate Professor and the Vice Chair of Research for the Health and Community Systems Department at the University of Pittsburgh School of Nursing, participated in the development of the workshop provided by the MoH to introduce the Code of Ethics for Nurses.

Authors

Richard Henker PhD, RN, CRNA, FAAN
Email: rhe001@pitt.edu

Richard Henker is a Professor at the University of Pittsburgh School of Nursing. He has been working as a volunteer at Angkor Hospital for Children (AHC) through Health Volunteers Overseas (HVO) since 2006. Initial volunteer visits at AHC focused on advancing practice in the Anesthesia Department at AHC and developing a clinical site for University of Pittsburgh School of Nursing students. Subsequent visits to AHC have also included working with the Departments of Nursing, Nursing Education, Medical Education, External Programs, and the Sotnikum Satellite Hospital. Nineteen University of Pittsburgh School of Nursing students have been involved in clinical rotations at AHC., Rick has collaborated with Manila Prak, Virya Koy, and the Ministry of Health on policy projects that have included implementation of the Code of Ethics for Nurses, and the Scope of Practice and Standards of Care for Cambodian Nurses. Rick is Chair of the Nurse Anesthesia Overseas Steering Committee with HVO and is on the HVO Board of Directors. He is currently the co-chair of the American Nurses Association Committee on Nursing Practice Standards.

Manila Prak RN, BSN
Email: virya2403koy@gmail.com

Manila Prak has been employed at AHC since 1999. She became the Nursing Education Coordinator in 2003 and eventually became Director of the External Programs Department. The External Programs Department has received USAID funding through URC since 2010 to support their work in Cambodia. Manila was appointed the regional director of Quality Health Services for USAID in 2014. She currently serves on the International Board of Directors for AHC.  Manila has spent time at the University of Pittsburgh School of Nursing in 2009 and 2013 where she has both lectured and taken continuing education classes. She is pursuing a Master’s degree at Chulalongkorn University in Bangkok, Thailand. Manila lost two brothers during the unstable time after the civil war in Cambodia.

Virya Koy, RN, SNA, MNSc, MHPEd
Email: pmanila@angkorhospital.org

Virya Koy is the Chief Bureau of Nursing and Midwifery, MoH; President of the Cambodian Council of Nurses; and Vice President of Chenla University. He was appointed to the role of the President of the Cambodia Council of Nurses by the Minister of Health of Cambodia. Mr. Koy is a nurse anesthetist and is currently pursuing a PhD in Nursing at Chulalongkorn University in Bangkok, Thailand. Mr. Koy is the representative for Cambodian Nurses and Midwives for the ASEAN joint coordinating committee in nursing. He is also the Cambodia focal person for human resource development with the World Health Organization.

References

American Nurses Association. (2001). Code of ethics with interpretive statements. Silver Spring, MD: ANA.

American Nurses Association. (2010). Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org.

Angkor hospital for children. (2015). Available: http://angkorhospital.org/treatment/outpatient-department/

Cambodia, Ministry of Health (2008). Health strategic plan 2008-2015. Retrieved from www.moh.gov.kh/files/dphi/HSP0815En.pdf

Central Intelligence Agency. (2015). The World Factbook. Retrieved from www.cia.gov/library/publications/the-world-factbook/geos/cb.html 

Heuveline, P. (1998). Between one and three million': Towards the demographic reconstruction of a decade of cambodian history (1970-79). Population Studies, 52(1), 49-65.

International Council of Nurses. (2012). The ICN code of ethics for nurses. Geneva, Switzerland: Author. Retrieved from: http://www.icn.ch/images/stories/documents/about/icncode_english.pdf

McGrew, L. (1990). Health care in Cambodia. Cultural Survival Quarterly, 14(3) Retrieved from www.culturalsurvival.org/publications/cultural-survival-quarterly/cambodia/health-care-cambodia

Sub-decree Code of Ethics for Cambodian Nurses. (2014). Ministry of Health. 

United Nations Statistics Division. (2014). Millennium development goals indicators. Retrieved from http://unstats.un.org/unsd/mdg/SeriesDetail.aspx?srid=553&crid=116

U.S. Agency for International Development. (2010). URC better health services. Retrieved from: www.urc-chs.com/project?ProjectID=6

World Health Organization. (2009). WHO Country Cooperation Strategy World Health Organization Retrieved from: www.who.int/countryfocus/cooperation_strategy/ccs_khm_en.pdf?ua=1.


© 2015 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2015


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