My Scope of Practice: Cambodia, or Bust!

  As a Public Health Educator, Fran Sculley, RN, MSN, provided outreach services to underserved elder populations in five Massachusetts towns. Among her constituents were Hispanics, Russians, and a Cambodian population second in size only to its counterpart in Long Beach, Calif. Faced with the knowledge that her Cambodian patients were not always receptive to American healthcare offerings, Fran wrote a mini-grant to secure the services of an interpreter who could better help facilitate blood pressure and blood sugar clinics held at the town’s Cambodian temple.

Additional funding and the support of the local community health center utilized by the Cambodian population – and later, help from the community hospital and the Department of Public Health’s department of refugees and immigrants – allowed the “Cambodian initiative” to grow. Eventually, the funding dissipated but Fran’s interest in the culture and concerns of the Cambodian people continued to flourish. She learned of opportunities to serve abroad through the Association for the Advancement of Wound Care’s (AAWC) World Wound Care Alliance (WWCA) and now looks forward to treating Cambodians not only in her “backyard” but also in theirs.

  Fran has a Master’s degree from Salem (Massachusetts) State College. Her career includes med-surg and ICU nursing and teaching. Volunteer work with her local Board of Health segued into a position at the elder service agency; “stair-stepping” to success, she helped nurture educational programs for the public as well as for healthcare workers. “The entire project became a collaboration within and among agencies,” Fran says. “When I eventually left, the project was controlled by the younger Cambodian healthcare workers and interpreters whom we had given the opportunity to become decision-makers for their community. One young man trained as a podiatric aide. Another who had lived on the streets and served as an interpreter now works on immigrant issues. By being sensitive to and respecting Cambodian culture and values, we were able to open up this ‘closed’ community to better care.”

  Fran relates her experience trying to take the blood pressure of an elderly monk. By tradition, a woman should not touch a man but the gentleman accepted her as a “doctor” as well as a non-Cambodian who may not be familiar with the taboos. She also understands that the Cambodian people have seen a great deal of death and have grown distrustful, feelings magnified by the fact that many of their young have gone to hospitals and died. She has studied their history and absorbed their personal stories. Plus, she is an adventurous eater and knows not to offend her patients by refusing their offers of food.

  After holding several positions that were not as clinically or personally fulfilling as her work in public health, Fran is now a Clinical Nurse Manager of the Wound Healing Center of Anna Jaques Hospital, Newburyport, Mass. “It is like a return to public health combined with management and the clinical aspect of a up-and-coming wound healing practice,” she says. “What could be a better blend?”

  But something was still missing. “I attended the Symposium on Advanced Wound Care this year in Tampa and heard of the outreach initiatives for underserved communities around the world,” Fran says. “I called my husband who said ‘Go for it.’ I will be working with the WWCA to find an opportune time to visit Cambodia and once again help provide care to its people.” Fran hopes others will join her in her mission to Cambodia. She enthusiastically offers a few factoids regarding the Cambodian people and what outreach workers might encounter.
    1. Cambodia is a war-torn country full of rural-living people. Although they have experienced unimaginable horrors, it is acceptable to ask them about their past. You will know when they prefer not to discuss it, but you can still ask.
    2. If you are working with patients or native staff and see that people around you are laughing, ask what is funny. They have a wonderful sense of humor despite their history. You may find they are laughing at a major error of yours. They appreciate when you try to abide by their customs but acknowledge that you are not of their culture; therefore, they do not hold you to their way of doing things. They enjoy a good laugh when you make mistakes or when they recognize differences between cultures.
    3. The Cambodian population has a high incidence of hypertension and diabetes (soy and fish sauce and sticky rice do not help). Don’t try to tell them a serving of rice is 1/4 cup – otherwise, see “ laughing,” above.
    4. HIV has been spreading rapidly throughout the country.
    5. Most Cambodians are Buddhists. They are open to outsiders. The celebrations are wonderful. You will be offered food and it is rude to refuse. Be careful. Some is spicy for those who are not used to it. The closest cuisine is Thai.
    6. You may be expected to take off your shoes and sit cross-legged on and rise gracefully from the floor. Dress accordingly and practice stretching out. It is embarrassing to be unable to achieve these movements when a 90-year-old can without groaning.
    7. One night, after months of working with the people, my associate asked why there were so few men, expecting to be told it was not appropriate for female workers to care for them. The answer was a matter-of-fact, “Because they’re all dead.” It brings home the tragedies these people have endured. Related to their history, you will see a high incidence of post-traumatic stress and depression. You may have to deal with these as the “spirits” that have caused health problems, especially mental health issues.
    8. American and Cambodian health-belief systems don’t mesh. You may offer medicine for an illness and hear “Yes” repeatedly when you explain how it works. There may be no follow-through unless you enlist the aid of family members. This may seem anti-HIPAA but you are in a community-based culture.
    9. Expect many herb-based home remedies and cupping and coining. Coining involves dipping a coin in heated oil and rubbing it on the skin to cure illness and/or chase spirits away. The practice is sometimes used along “lines” of the body in a manner similar to acupuncture. Some Westerners misunderstand the subsequent red marks as abuse. Cupping is used for similar purposes. Special cups are heated and applied to areas of the body. The heat creates a vacuum; when pulled off (to release toxins or spirits), the suction leaves welts. Clinicians would do well to incorporate these practices into their care protocols or risk rejection.
    10. Understand the need to develop trust. Although your patients may be drawn to your care center by its reputation, you still may have to overcome the “walls” these people have had to develop to survive. Making a small impact can begin to open doors to additional assistance in the future. Fran is somewhat surprised that many of her former patients remained eager to return to a land that harbored memories of trauma and hardship. They are not unlike her –exposed to the best of America but with strong ties to a people and place that offer a sense of coming home. Fran is not to be discouraged from her plans. “As many nurses will tell you,” she says, “some of my best work is accomplished when I’m told it can’t be done in my scope of practice.”

My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.