Every year, University of Arizona College of Nursing Clinical Assistant Professor Kimberly Shea, PhD, RN, CHPN, receives many requests from international students hoping to partner with her for postdoctoral research. With her demonstrated passion for informatics, telehealth, hospice and palliative care, her area of expertise is unique. Frequently her correspondents lack either a nursing background or informatics training. But when she received an email from Lek Nisa Wongchan, a palliative nurse with interest in telehealth from Bangkok, Thailand, enrolled in the Prince of Songkla University (PSU) Nursing PhD program, she took notice. Lek’s extensive palliative care experience in Thailand, and her desire to learn from the U.S. system, was appealing. The cultural and practical differences between the two systems seemed like fertile soil for an exchange of global health care ideas.
"I would like to create a new model for helping people in urban areas. If we had a physician in the team, as well as other supports, they can help the caregiver and decrease the tension. It’s a first in an urban city like Bangkok.” ~ Lek Nisa Wongchan, palliative care nurse from Bangkok, Thailand
After clearing a slew of bureaucratic hurdles, Lek arrived in Tucson, aided by a four-month scholarship from Navamindradhiraj University in Bangkok, where she is a lecturer at the Kuakarun Faculty of Nursing. Her goal was to learn more about the use of telehealth in the U.S. palliative care system, but she brought with her a passion to not only learn but also to share her knowledge of Thailand’s end-of-life care traditions and methodologies.
Lek has practiced palliative care in her home country for 14 years, but the differences between the two systems are significant. In Thailand, nurses’ tools for helping people to remain in their homes throughout the end-of-life journey are limited. Nurses are solely responsible for all facets of palliative care, while in the U.S. they have a support specialty team comprised of multiple disciplines, including physicians, social workers and chaplains. In urban areas such as Bangkok, patients who wish to die at home are stymied by a lack of support that results in undesirable admissions to the hospital, where they can receive hospice care.
“If the patient would like to stay to live at their home,” Lek says, “they may not be able to because they don’t have anything to support them. There are no physicians, only nurses, and nurses cannot prescribe medication for the patient.” Using the knowledge she gained during her time at UArizona Nursing, she hopes to change that dynamic.
Her PhD dissertation presents a multi-disciplinary model that she created and plans to test in Thailand. “I would like to create a new model for helping people in urban areas,” Lek says. “If we had a physician in the team, as well as other supports, they can help the caregiver and decrease the tension. It’s a first in an urban city like Bangkok.”
Dr Shea explains, “Lek is trying to create a new model for the healthcare system, directed by the Thai government, to provide multi-disciplinary care for home-based palliative care.”
“In Thailand, the palliative care model is just the nurse going to the home,” says Lek. “But here the palliative care model includes multiple disciplines, so there’s a social worker, a chaplain and also the medical director, if needed. Dr. Shea helped me to learn the whole system here -- in education, community, the hospital, hospice care, and in-home care. Now I can compare.”
That comparison led to a fertile exchange of ideas between Lek and the health care hospice and palliative care professionals she worked with in Arizona. “In Thailand, hospice care is inpatient, as opposed to palliative care, which goes to the home to enable patients to stay at home until they die,” says Dr. Shea. “The difference between hospice and palliative care is very clear, unlike here, where we have a home hospice program and the inpatient unit is for use only when symptoms are not controllable in the home. Yet, palliative care cuts across all types of care because it’s about providing comfort. We’ve learned a lot from Lek because of their approach to palliative care is very spiritual, while ours is often very physical.”
Thailand’s undergraduate nursing programs require students to pass religion and ethics classes before they can begin their 3-month palliative care studies. Over 95% of Thai people practice Buddhism, where Making Merit becomes heightened during the final stages of life. Making Merit is a fundamental Thai Buddhist practice that focuses on the purpose and value of each day that is enhanced by good deeds, acts or thoughts. U.S. palliative care practices help patients to satisfy goals as opposed to focusing on fulfilling an individual’s purpose each day, an idea that struck a chord with the palliative care workers Lek encountered at Casa de la Luz Hospice. “The idea of each day having a purpose was a big ‘Aha’ for the nurse practitioner, social worker and chaplain,” says Dr. Shea. “That really clicked. They were so excited to learn from her.”
Lek shared her knowledge of Thailand’s universal health care system with UArizona Nursing Bachelor of Science in Nursing (BSN) students, visited simulation classes with Master’s Entry to the Profession of Nursing (MEPN) students and went on palliative care visits with Casa de la Luz staff. Dr. Shea saw possibilities for more palliative care education but stated, “It’s hard to add any additional class time to our undergraduate nurses because, as educators, we have an obligation to provide the knowledge that will allow students to pass the Nursing Certification Licensure Exam (NCLEX) and there aren’t many palliative care questions.” Then added, “But I think there will be more emphasis in the future because we are seeing greater emphasis in this area.”
Lek’s visit to UArizona Nursing will hopefully be the beginning of a new international exchange of ideas, especially with the College’s burgeoning focus on global education. “That give-and-take has been so exciting, because it opens our eyes to other possibilities,” says Dr. Shea. “It’s one thing to read about other ideas and practices in the literature and say, ‘Oh, I read here that they do it this way,’ and another thing to actually talk to somebody who’s living it.”