Welcome to Nursing in Hawaii blog

I don’t often add to this blog these days. Most often I blog at www.joeniemczura.wordpress.com and I invite you to go there. That other blog is pretty much focused on health care and nursing in Nepal (and by extrapolation, South Asia). And even there I go through fits and starts of activity. As you may guess, I am more active when I am actually in Nepal. Interacting and having dialog with my colleagues there provides inspiration for new commentary.

When I was more active I tended to write about issues faced by new graduates when entering the workforce, from the perspective of being a faculty member who was sending them forward with great pride and hopefulness.


I loved Hawaii during the ten years I lived there, and I wish every nurse could have gotten the positive reception I did. The spirit of Aloha is real. I think people from Da Mainland expect that somehow everyone is happy-go-lucky… some sort of cartoon stereotype of what it means to be “native.” But the spirit of Aloha is something you can adopt as a hard-working member of the community.

One of the big surprises is the intelligence and work ethic of the average nurse or health care worker in the Aloha State. Hawaii is a model of how to have a diverse society for the rest of the USA.

Books, did you say?

I also have written two books, on the subject of health care in Nepal, and these can be obtained via Amazon. There is a separate blog for the second book, The Sacrament of the Goddess. I have been asked when the third will come out. Usually the question comes from a person who has no idea what it entails to write a book, (even a book as humble as mine). The answer? I don’t presently think I have it in me to devote that kind of obsessive effort.

Right Here, Right Now

I am back on the mainland USA, this time in Florida where my relatives have established a beachhead. I teach nursing to – “beginners.” This is the most fun level at which to introduce what it’s like to do this work. I am fortunate to share my job with colleagues and administrators I respect and enjoy.


Feel free to browse this blog!


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Part Two: How to Get Soul if Your lab doesn’t have it

Note: I spent nine years as a critical care manager coaching staff for peak performance during crisis situations, and I know a thing or two about psychomotor skills performance under pressure (which we’ll get to in a future blog). If your educational practice does not incorporate elements of sports psychology, you are missing the boat. We want our team to win and our players to love the sport.

Yesterday the blog entry here was titled “Does your Simulation Program have “Soul?” http://wp.me/p1Kwij-nF and it was a teaser. I just laid out  the problem but didn’t offer the solutions. In the education business this is called “creating the need to know”  – It’s like catching mice. When the mice are hungry enough, even the worst cheese is alluring and irresistible.

Um, maybe not the best metaphor. My professional colleagues are not laboratory specimens running a maze. The point being, I know I am not the best writer – let’s focus on the aromatic cheese (me) , not the mouse (you) per se. Words sometimes fail me but I still try to speak my truth.

And – it was a joke.

Floor Plan and square footage

So the first set of solutions to developing a heart and soul for your sim program/lab is in the physical layout. If you look back at yesterday’s blog I was pointing out things that could have been mitigated with better design and more space. Now, space is a problem when a sim lab and/or skills lab is retrofitted into a previously existing space. But – there does need to be adequate waiting area and closet space.

I’m told there is a specialized architectural firm that houses a specific team to design these “state-of-the-art” labs everybody is trying to have.

Think of the actual sim room, or even the actual skills lab, as if it were a ride at Disneyworld, or perhaps a room in an O.R. suite. There needs to be a place for the next batch to wait, and a room at the exit doors for the previous batch to exit. The room gets turned over for the next batch. The ideal is to have a de-briefing room right next to the actual sim room; but if you need quick turnover it’s actually better for each group to exit the area when their scenario is completed.

tip: If you are in a cold climate, expect that the students will wear a winter jacket, they will need to hang it up, along with boots and book backpacks.

If the lab is so tightly scheduled that groups of students need to wait outside and then flood  in as soon as the class time begins, you need to think about the waiting area. tip: Give them chairs. Designate a staging area nearby. You may think this is obvious, but it’s not. given a choice between students sitting on the floor versus a cluttered hallway, I’d be happy with clutter.

“A well organized desk is a sign of a cluttered mind”

I have now seen a number of labs where they simply didn’t design enough closet and storage space, or it’s not efficiently done. You can’t wait to set up a lab event by beginning at the start of class time.

The logistical chain goes like this:

The students arrive > the equipment is there and the disposables are too > the class happens > the process is repeated for the next “performance” with a new audience. Maybe the same equipment and disposables, maybe a different performance altogether.  Dos it sound too basic? may be for you it will, but maybe a new faculty never really thought about it before.

Failing to execute logistics is like waiting until the code starts before you stock the crash cart. From the beginning, effective lab management needs to build in the prep time and a system. tip: think of the supply logistics the way an O.R. nurse would. In late afternoon, You look at the cases for the following day, and pull the equipment needed, placing it on a rolling exchange cart. tip: don’t overbuild shelving for storage. exchange carts give you a more flexible system.

Eye Candy from Johns Hopkins

This YouTube was going around a week or two ago, and it showed JHU doing the “#mannequinchallenge  I would point out several things. First, the JHU Dean has enough of a sense of humor to make a cameo appearance at 1:42. Next, each little tableau is posing for a different activity (you would never have all of these things happening simultaneously even if they were on drugs, which they are obviously not). Thirdly, I suspect they have “soul” down there…..  to me, the video implied a sense of giddy fun. The best way to learn.


tip: every time you can think of a way to have the students “own” the lab, implement it. If a student shows up early before the first class of the day – let them in, and engage them in assisting you setting things up.  You are modeling planning skills when you let them in on the secret. tip: At the end of a session? always end the content delivery five minutes early so the students clean it up, not you. Your energy should be directed toward preparing for the next class, not cleaning up after the previous one. You as lab manager are need to focus on finding ways to create, not simply do the laundry or clean up after the event. Having said that, there does need to be a system to put stuff away so it will be in ready condition when it is next retrieved. tip: at the end of each session, thank everyone who helped do the behind-the-scenes with you. Or even during the session you can ask them to stand and get a round of applause. (Yes, groups are often inhibited from doing any “spirit” things – but time to break that expectation and create a new one. Being willing to create positive motivation in this way is a behavior that will carry  over into clinical practice and become just as critical there as sterile technique).

I think this is enough for today. If you have tips to add please make a comment.

Tomorrow is part three

Tomorrow I will write more about ways to get “soul” and create a love of sim and a love of lab. If your students seem to dread a psychomotor session, never fear! the secrets will be revealed! Be sure to subscribe to this blog to make sure you don’t miss anything. Also, if you have faculty who don’t get it in terms of how to use lab to revolutionize attitudes, feel free to forward this to them….why not!?!??!?!!






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Does your Simulation Program have “Soul?”

Because I use Sim in Nepal and have been involved in scenario-based education, I have interviewed for about five nursing faculty jobs here in USA where they are looking for a person to run their Sim Lab. I visited a School of Nursing not too long ago where the corridors were sterile. You know the kind of place I mean – maybe you work at one. When I walk around such a place I can hear my own footsteps. Every door is the same and every person is dressed like a bank executive.

They showed me their learning lab. Outside, thirty students waited in a corridor – sitting on the floor because nobody thought to set chairs out there. Two huge bulletin boards – with nothing on them. A monotonous color scheme, nothing on the walls, everything very neat. (had it ever been used?)

I do not recall the source of this meme. It can be seen in many skills labs. Which one do you prefer?17390843_1499830790048183_2928056301606602728_o

Nursing students were doing scenarios with Sim Man, and I overheard one faculty member needing to stop the scenario to instruct the student on female catheterization technique. They were using Sim as a means of individual evaluation, no audience other than the faculty. Punitive overtones if you ask me. There was no nearby practice/pre-test prep area that I could discern.

Two international graduate students who looked like they were Somali, sat at a table reading. They were there to work with the undergraduates, but – they didn’t seem to be interacting at all.

Are we having fun yet?

It reminded me of this:


When this dynamic is ingrained into a corporate culture, it is difficult to overcome


Yes folks, the literature of Scenario-based education is replete with examples of joyous learning described as “transformative.” But – your school can invest in all the manikins, build a multi-million-dollar Skill and Sim suite, and – still not “get it.”

I’ll admit, during the tour I started to compose a list of strategies that might help them grow. The faculty had a comfort zone – it was just not in the right place.

I guess my question is, “what are we teaching the students when the environment is like this?”

We’re teaching them they don’t really matter. They are cogs in a corporate machine and we are teaching them to say “Do you want fries with that?” When we adopt the micro-managing of interpersonal behavior, we now control how they interact. Because of closed circuit cameras and two-way mirrors we now have the capability to document whether the person is smiling enough.

Consistency is a goal, but – does that also mean “conformity?”

Got Soul?

A simulation/scenario-based education program needs to have a certain joie de vivre in order to capture the student’s imagination and engage their passion. Help them love nursing not dread it. That’s what I call “soul.”

Here is the point where we all go look it up and present the dictionary definition. Soul is not strictly a religious term. For a bit of edge I always seek definitions at Urban Dictionary.


having an outstanding aura, with a brilliant and loving attitude.
Being exceptionally well at a task.
Completeing a task with an indellible inquisitive nature or spiritual quality.
I love this job I do it well cause I got soul.

source: http://www.urbandictionary.com/define.php?term=Soul&page=2

Here’s another one:


Technically: a religious concept of an immortal individual conciousness, the mind superimposed on an invisible and supposedly indestructible and universal substance called “spirit.”
Colloquially: authenticity, style, or passion. Used almost exclusively in expressions similar to “he’s got soul,” often used to refer to individual (e.g. improvisational) expression in music styles such as jazz.
Also, a harmonically simple, often syncopated, style of music made by black people such as James Brown, usually played by small groups, though occasionally involving horn sections, related to funk and rock and always having vocals. This music is claimed to embody the above characteristic.
Everything they did, seemed designed to remove the authenticity, style and passion.
They didn’t offer me the job.
Not sure I wanted it, after all. 
Next blog entry? Part Two is live as of Monday Dec 5th. The title?  How to Get Soul if Your lab doesn’t have it.  Here is the link: http://wp.me/p1Kwij-oY

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“Friday Night at the ER” is also Simulation and – your school needs it!

It’s been more than a year since I posted in this blog, but the all-time top two entries are still attracting views. the first is “Myths about becoming a nurse practitioner – things to consider about grad school in nursing”  http://wp.me/p1Kwij-au and the second is “part 1: Secrets of a Nurse’s Brain – six steps to success at clinical practice, or anywhere!

I mostly blog about Global Health nursing and Nepal healthcare these days since I no longer live in Hawaii. go to http://www.joeniemczura.wordpress.com

Friday Night at the ER and Scenario-based education strategies

These days one of the trends in nursing education is to adopt scenario-based learning. Most often this turns out to include investing in a skills lab upgrade so as to incorporate much more sophisticated training manikins that require use of a computer as well as a trained operator who can make the manikin breathe, talk or have a cardiac arrest. These are wonders to behold, and supported by marketing from the main company that sells them. Over time, this approach has built an eco-system of professional journals, conferences, web pages and user networks to support dissemination of wisdom about how to provide simulation. Your simulation site can get certified, and there is a book of Standards you can use for ideas.

I’ve been in favor of scenario-based education for a long time, probably ever since I became an EMT in 1975. (was still in nursing school at the time). The American Heart Association uses “megacode” scenarios to advance psychomotor skills and I always enjoyed the game aspect of this approach. In Nepal, I use scenario-based education to promote better critical care response. Minimal lecture, lots and lots of role play.

Scenario-based education is more than just the fancy manikin.

In 2002 I was hired by a school of nursing that suffered a dismal NCLEX first-time takers pass rate and decided to replace some faculty members. Voila, because of my prior management experience I was now teaching the Management and Leadership class with a specific mandate to focus on delegation skills.  I re-wrote the course outline to include activities for this. I was determined to teach it in a manner that reflected the real world.

“Delegation is very boring as a lecture topic, up until that exquisite moment when you realize that you are in legal trouble and could lose your license if you do it improperly, then all of a sudden it is crystal clear and very exciting” I used to say.

Friday Night at the ER is a key vehicle to teach concepts of nursing administration firsthand, that go on all the time, but which nobody ever explains to the new RN. The processes in the game board are extremely well-designed to illustrate the ongoing slog of bed-control and patient flow-through decisions, and players get to apply them. The scoring reflects the financial incentives associated with these processes. Sometimes schools of nursing will assign each senior to shadow a house supervisor for a day to get exposed to these things, but this is a hit-or-miss prospect; Friday Night at the ER guarantees that each participant will get the feel of being a house supervisor.


One game board. Best played in a rally format with may game boards. Like Monopoly, there are many twists and turns and the outcome depends on certain skills possessed by the players.

It’s a game board. And each board accommodates four (maybe five) players. Do the math. A cohort of thirty will require six or more game boards. We had a cohort of fiftysix, and divided the experience into two halves, with eight boards each day. To fully implement it at your school requires buying a set of game boards (I took this to another large school of nursing and once they committed they bought eight game boards) and it requires logistical set-up ( lot of small pieces need to be set out on the board, like Monopoly). Also, the way we did it required an all-day scheduling commitment, taking about six hours to include two de-briefings along the way. A strong recommendation? don’t try to squeeze it into just one three-hour class sessions. Do it in lieu of a clinical day.

If you adopt Friday Night at the ER?

Facilitator: Like the manikin-based approach to simulation, the facilitator of Friday Night at the ER does a better job if they also have real-world experience as a mid-level manager, because they have a better idea of the relative value of insights  available during an open-ended event such as Friday Night at the ER.

Debriefing: the academic nursing journals and websites devoted to manikin-based scenario learning are amply stocked with testimonials as to the need for debriefing, as a means to frame the experience. Like using a manikin, it’s possible to do the experience and not actually learn anything or gain insight. De-briefing is absolutely critical. If you adopt Friday Night at the ER,  you need to include ample time for this, and the students need to commit to the idea that they can’t run out of the class as soon as the last score is tallied up.

Integration: Friday Night at the ER is billed as “discovery learning”  and the company that sells it will tell you not to pre-warn the participants in advance as to how to “win” or to share the scoring system, etc.  This presents a challenge, because it’s harder to “sell” people on the merits of playing. In addition to the usual suspension of disbelief required for good simulation, Friday Night at the ER is more fun and experiential when you all learn as a team ( that’s why it is used by non-nursing and non-health care teambuilding consultants – it forces people to communicate and problem-solve.)

Having said that, since the game applies principles of delegation and illustrates they way a health care organization works, you can prepare the students to play it as part of a sequence of learning about delegation, the Nurse Practice Act, etc. I wrote a four-part sequence of blog entries to describe the how I taught delegation, right here on this blog.

Where to get Friday Night at the ER

go to http://blearning.com/

Disclaimer: I am not associated with the company in any way not am I being compensated for this full-throated endorsement in any way. I am merely a satisfied user since 2003. I have led this exercise about forty times I think. (memory is a bit fuzzy). I am very experienced in use of scenario-based education for critical care, especially debriefing.

While we are on it, the company needs to grow their followers on Twitter. go to @TheERGame and you will find them. pass the word!

My other blog entries on this topic

The first was part 1: Secrets of a Nurse’s Brain – six steps to success at clinical practice, or anywhere! This one addresses personal organization to promote personal accountability, the first step to understand delegation.

The second was part two: checklist culture and your role in quality

The third was How to teach delegation and the Nurse Practice Act, part 1 dec 29 2013 This one explores how delegation is defined in (most) state Nurse Practice Acts.

Another was teaching delegation and the Nurse Practice Act, part 3 Jan 1 2014 This one will show you a free resource from NCSBN that is absolutely critical for every school of nursing to teach, and for every future NCLEX test-takers to read.

And finally, to teach delegation part 4 – getting “street smart” Jan 3 2014 How an organization made up of individually-accountable nurses will support legal practice.

Here is my offer to consult with you on delegation issues in the curriculum

As you can see from the above, I believe strongly that delegation can not be “integrated” into the curriculum as some sort of subliminal brain telepathy. Subtlety does not become it, delegation needs to be laid right out there and preached. And, delegation is not well delivered when presented by a “talking head” as a dry academic experience.   In the paper “Working Well With Others” from the National Council of State Boards of Nursing (NCSBN) a key statement is:

“The strongest set of delegation rules will not work unless the nurse possesses the interpersonal communication skills to enforce them” (paraphrased).

The best way to hone interpersonal skills is to use them and get feedback.

Please note: the Friday Night at the ER site lists experts you can hire. UPDATE: at first glance I thought there weren’t any  nursing educators, but I have been gently reminded (below)  that there are two – Dr Mary Dolansky at Case Western, and Dr Carol Durham at UNC. They come highly recommended.

Dr. Mary Dolansky’s  page is https://nursing.case.edu/about/directories/faculty/dolansky/


Dr. Carol Durham’s faculty webpage is http://nursing.unc.edu/people/carol-fowler-durham/

I plan to ask Breakthrough Learning to add me to their list. If your school’s aggregate NCLEX scores show the need to buff up the area of delegation,  I will happily work with you to revise the senior-year curriculum, including coming to your school to help you do it (for a fee). Alas, I do not own any of my own game boards. You would need to buy or rent these on your own.


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Hello from USA October 15th

Welcome to this blog.

Feel free to browse. There’s lots of advice for new nurses here.

You will see that I have many interests, and I’ve written two books. These days I am spending more time on my Global Nursing blog. Periodically I go to the country of Nepal and teach nursing there.

I spent 2014-2015 in Nepal and yes, I was there for the earthquake.

My second book is fiction. I wanted to describe the role of women in Nepal society. This was a more readable way to do it. Nepal is HIindu and Buddhist yet they fought a civil war. How could that be? The book looks at that question as well.....

My second book is fiction. I wanted to describe the role of women in Nepal society. This was a more readable way to do it. Nepal is HIindu and Buddhist yet they fought a civil war. How could that be? The book looks at that question as well…..

The earthquake shook up the political situation in that country. I am not a political expert, but one thing I noticed: the USA news is not covering the politics.

So lately I’ve been blogging on that. When, I post on DailyKOS. It’s got a different format which makes it easier for readers to find me.


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Sept 1st back in USA

Hi –

I’m back in USA and still following the Nepal news.

I’ m keeping this blog “up” but not focusing on it right now. My main effort has been going to the blog that accompanies my second book, the novel about Nepal.

Nepal is presently in political turmoil (to say the least) and you can read my thoughts about it here.

sending the best karma to all my readers.

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from CCNEPal about Joe Niemczura, post-earthquake April 26th, 2015

For readers of this blog, you know that it has not been active during this year that I am teaching critical care nursing skills in Nepal.

I am actively blogging on CCNEPal page, go there to read what I have to say.

For the record, I was in Bhairawaha Nepal on the day of the quake. In Bhairawaha, I noticed something odd at 11:56: the water in the glass was sloshing back and forth all by itself. I immediately got up, alerted the other people nearby that it was an earthquake, and we all left the building.

Here, nothing was damaged. not only that, but it was mild enough that things stayed on the shelves and tables. I spent much of the day (it was my day off) answering emails and messages to re-assure my friends that I was safe.  I am fine. I am not personally inconvenienced in any way.

I am on my long-planned “Road Trip” – fifteen sessions of my course outside the Kathmandu Valley. Five have been completed and ten remain. I am teaching today.

I would point out that CCNEPal, my organization, has trained 1,775 nurses and docs in Life Support skills, and about 800 are in Kathmandu. For that reason, I suppose you could say that CCNEPal has “pre-positioned” for this event (though I would not wish this on anybody). I am 100% certain that the Nepalese people will be helping each other, it is something I have always admired about this beautiful country. There is ample capacity to shift medical personnel from within the country, and I am sure that such a move will be easier than to bring in people from outside.  For those who wish to help, I guess the first thing is – send money to aid organization of your choice. (not to me!)

In general, I think it’s too early for nurses and doctors to come here unless they speak fluent Nepali and already know about the hospital system (most hospitals are intact). I do not think the needs will be quite the same as they were directly after Haiti, for example. Logistically, a self-contained team would be good.

From reading about other disasters in other parts of the world, I think that the early period will focus on recovery of victims. The time when foreign nurses can help will be down the road, when disaster fatigue sets in, and also to “backfill”  basic health services in unaffected areas where the Nepali nurses have and doctors have been shifted to Kathmandu.

We will all learn more as the full extent of damage is revealed in coming days.

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the perfect #NurseWeek present for the #nurse in your life, or for a new graduate

This blog entry will be brief.

Nurses Week comes up soon, in May.

Also, this year’s crop of new graduates will proudly walk on to the stage and accept their diploma.

If you need an idea for a present?

give them money.

But sometimes money is not enough, or too crass, so – buy this book. The Sacrament of the Goddess was written as an adventure story that will appeal to health care workers who have the daydream of using their skills in a Low Income Country. If you order it now it will get to your house before May 6th.

It’s a page turner, set in a hospital in Nepal during the Nepal Civil War.

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Nursing in Hawaii blog is still on Hiatus while I’m in #Nepal until May 30

Thank you for wandering into this blog site!

Though it’s titled Nursing in Hawaii, most of it is devoted to general advice about nursing. There are three blog entries that seem to get the most hits – look on the list at the right and you can see them in all their glory.

Work in Hawaii?

I do have specific advice for nurses from the mainland who want to work in Hawaii. In summary, if you enjoy the cultural stuff, you will love it here. You can maximize your fun by studying the different cultures of the patients and co-workers you will meet. Browse the blog entries to find the gems…. I love Hawaii!


You may wondering why the blog is suspended. Well, the answer is, I have been following a lifelong dream and working in Nepal for a year. I am making a difference in health care in this country, and every day I thank God for designing my life so I can do this.

Read my Book?

My second book is a novel about Nepal health care. It’s titled The Sacrament of the Goddess, and there is a FaceBook page for it. Click here to get to the Amazon site.  Also I have another blog, just for the book.

The book is enjoying popularity here in Nepal, as crazy as that sounds. Want to read a review in Nepali language?

I will return to USA after May 30th.


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2014 in review for Nursing in Hawaii

Most of my blogging has shifted to http://www.joeniemczura.wordpress.com while I am in Kathmandu. But this blog is still up. I am humbled by the fact it reached 124 countries.

Wishing you all success for the new year!

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 43,000 times in 2014. If it were a concert at Sydney Opera House, it would take about 16 sold-out performances for that many people to see it.

Click here to see the complete report.

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