Tenzin Lhamo 10-11-2023

00:00 We begin. Tenzin, thank you for coming. Today we begin this interview by giving our name, our age, the date, who we are to each other, that you have given permission to be part of this Storycorps St. Kate's project. So, my name is Mary Watska Lagaard I am 70 years old. Today's date is October 11, 2023. Tenzin was at one time my student, and now I see her as a colleague. She has given permission for this recording to occur as part of the St. Kate StoryCorps project. Now you repeat the same.

00:52 Hello, my name is Tenzin Lhamo I am 46 years old, and currently I'm practicing as a nurse practitioner in health partners. And I'm here with the interview with Mary Lagaard who used to be my professor, doing my master's school in St. Kate's And today's date is October 11, 2023.

01:19 So let's start off back aways. Tell me about your decision to become a nurse. What kind of led to that?

01:30 So I never intend or I have ambition or anything like that to become a nurse. However, after graduating my 10th class, I fractured my right ankle in India. We live in India as a refugee in tibetan settlement in the northern part of India. So during that transition, I was hospitalized in indian government hospital. So in India, the government hospital is one of the most access, very common layout of. For normal people who does not have, like, health insurance. And the private hospitals are very expensive for middle family to effort. So during my stay in a hospital, government hospital for two months, I came across that the hospital staffs as well as the healthcare team, the structures, the environments were really poor. And I really felt like I could at least become a nurse to educate or help out my future patients.

02:46 How did the education come forward then? I mean, where did you go to school and how did you end up moving from India to here?

02:59 So after 12th grade, I got admitted into Jamia Hamdart University in New Delhi, which is the capital of India. And over there I completed my three years of diploma in nursing. And then my parents already arrived in us because of a bill passed by senior George Bush to bring 1000 Tibetans to United States to help our backward community. So my parents arrived here, and through immigration process, I came to United States in 2006.

03:43 And where were you at that point? Were you in the cities, in the Twin Cities? Or were you somewhere else in the United States?

03:51 When I first arrived, I went to Florida to meet with my sister, and I stayed there for minimum of three to four months. And I kind of came across little culture shock. And then I moved to my parents in Minnesota, which I felt like a lot more diverse and a lot more. The city is more equipped for people who are newly immigrants. And the transportation, education, work schedule is very balanced here. And I know that the previous immigrants people have adapted here very well. So I knew that this city was perfect for me.

04:33 So can you tell us what your culture shock was in Florida? I mean, I think Florida's culture shock, so I'd be curious to know what your impression was.

04:43 So coming from India straight to Florida, you know, the place is really beautiful and breathtaking, which almost seems like it's out of a. Out of a postcard, which was hard for me to believe. But there wasn't a good enough transportation and I have no driving experience. And the cost of living was very high because I have anytime, when I see the cost, I kind of convert back to indian rupees. And even like a hamburger could cost $10. And I started to convert indian rupees. And then if it's $10 and if it's several hundred indian rupees, I couldn't afford it. And that's why I had some culture shock. And my sister, despite repeated explaining to me that I cannot convert it, but my mental setup is in that way. And also I was studying my nursing books to go through the broad exam and getting to their institute where they will train me for their NCLEx exam. It wasn't accessible. And I thought, maybe coming here to Minnesota, I can use transport and then get into this institute where I could train for their NCLEX exam. Because I knew that the trainings that I went through India wouldn't be enough in us, where us was at that time, experiencing like one of the top healthcare. So I know that I had to build the standards.

06:15 So where in the cities did you go then? And how did you find your way to kates?

06:22 So I arrived here in Columbia Heights in Minnesota. Columbia Heights, I'm so excited to say it because it used to be one of the city in the whole us, one of the top ten cities back then with the most diverse. If you walk around Columbia Heights, it's very multi diverse. The transportation is available there. And the first several years after I got through my NCLEx started to work. I didn't understand that as a nurse, you can go up and achieve further studies and become a nurse practitioner or a leader. Despite working as a RN or a bedside nursing, my concept is still low. And back in India, nursing is a profession where not all the family members would, you know, choose for. It's meant for. This profession is meant for people who have middle class or poverty. Because you are involved with the interaction with the male you have, you are touching. You're giving them nursing care. So it's a profession not everybody supports back in India. But however, coming here, I was working as a bedside nursing for several years, and I never understood the implications of their studying and attaining or obtaining a leadership in nursing till my colleagues in my bedside nursing, other nurses started to go back school. And then it kind of triggered me thought, like, why are they going back to school? Because I felt like working as a bedside nursing. I'm making enough money, and that was enough for me and my parents. But later I did understand that it's not about the money, because I was newly from India, and I started to all think about this dollar, but it's not the money. It's how I transition to become a nurse and how I can be advocate for my patients and how I can change the health structures. Because working as a bedside nursing, especially in Hennepin county, is one of the most difficult fields because you see these patients who have so much barriers to the healthcare, and they are coming back again and again. It's kind of like patients are getting recycled. So at that time, I knew that I completed my bachelor's from Bethel University in 2013 to 14, which took me longer than other students because I completed my generals from India. So I had to fulfill, I think, about 40 credits. So that took me about like three years. And so I came across those whole credit, and I met those, and then I decided to apply for masters. But I knew from my friends that getting admission in St. Kate's which is one of the top universities, and it's very challenging. So I put up my application, and I had to write a cover letter, and I kind of freely expressed what I have went through. And I went through the interview, and one of the professor did ask me, why did it took so long for me to get back school. And I told her what exactly I felt, and I think she liked my story. And then I was accepted in St. Kate's

09:51 In many ways, you are a perfect person for St. Kate's, primarily because. No, I think you are and have been and will continue to be because of your whole focus on advocating for the patient and kind of in freeing up the patient to work on their own health. All these social barriers that we put in place that really don't help them. We were the ones that were lucky to have you on board. And I thought I even felt that very much in the class when you were with us. So. Yeah, and so, and I learned a lot from you. Let me just put that down there too. So describe what kind of career you have now and kind of going from kates to this career and how it's kind of changed too, as you've stayed there for a bit.

10:53 So in some case, I learned the masters of nursing practice in adult gerontology. And after graduation, just like any other colleagues, I had difficult time finding a job. However, I was able to secure a few positions and then finally I landed up a job in health partners internal medicine. Now my job, my responsibilities in primary clinic is seeing 40 or maybe 18 and above as a part of our preventative healthcare and then many office visits. There are so many things that I have learned in the class, especially focusing on the geriatric population. And when you see patients, especially the geriatric population, and you can apply those concepts. My favorite thing is as a part of a Medicare annual wellness visit, I often begin with, what is the living situation? How did the patient arrive to clinic? Who, what kind of resources the patient has available? Sometimes I think that question may be too much intriguing or too much personal to patient. And I do explain that, you know, I want to understand the living situation of my older folks and my patient age range from twenties to like hundreds. And I know that these questions apply very diverse to all of them. Whereas I'm 101 year old living alone and then grandchildren living with them. So is that a safe practice that I would often check? And then my patients in twenties, I always make sure that they have a living situation in our apartment or house or I came across one patient who was living in a car, which I kind of make sure that she's connected to the social worker. So learning all those concepts in school and then applying at our primary setting, I feel like this is exactly what I wanted. But there are many times that I do have to collaborate with other internists, and I often come across with them and then get their perspective and see how do I approach this case.

13:24 It seems like you greet patients where they're at and you try to understand their story from the time you start the interview at the beginning.

13:36 Yes.

13:37 Yeah. And build on it. So what would you like to do next? Or how would you like to grow this?

13:54 So I believe in healthcare every day is learning. And one of my boss always tells me that take a time out to read article or learn anything new from the healthcare journal, and this is what I had been practicing. But at the same time, I am taking classes for my DNP doctor of nursing practice and I am down to two classes left. So I know that the concepts and the leadership strategies that I have learned in the DNP I could apply, let's say for in case in the last several months we have the second largest tibetan community in Minnesota from all over the United States and I was elected as a board member. So among that board member, when we were distributed with portfolios, I selected education because that's the area I have struggled so much and I know that at the same time I have learned, but I never felt like I learned enough. I always apply the concept that it's never too late to learn. And because of that, what I'm learning in my DNP leadership I could apply, even though I'm not applying the concept directly in the healthcare, but I'm applying that in a community setting. And our community, which is the tibetan community, we have about 7000 people and very diverse. We are dealing with the young first born generation as well as we are dealing with the older generation. So working as a board member for them and among the other board members with a different age is often challenging. But I always try to bring out the, some of the leadership skills that I could present and at the same time we try to use those, whatever I have learned to build and initiate a future plan. Recently we initiated a new program for preschool for tibetan young parents and where the children's were three, four, five year old. I thought this preschool program for these new parents are so important because I know as a parent I have struggled when my children were not speaking good English or making full sentence at age three and they were not able to verbalize their concern. So I know that these age of 2345 are so important and not the new parents should not give up speaking to their children in Tibetan. So, and I can provide a platform and a classroom for them and then pull up all the resources like teachers and then I'm working with the grant where I could provide resources for the teachers in a setting that we are using and to confirm with the parents that yes, we all are struggling because our Kate's our children are not meeting the outcome as other children in America. However, our struggle is different and our struggle can be slow, but we will come across by our children learning the tibetan language as well as the English.

17:43 I'm just so proud of you for taking that on, that is such a, such a worthy project. I mean I can see how it marries your culture with what education you've gotten here in America to improve your community and I think this is probably just the beginning for you, but it seems like you enjoy the work. Is that true too?

18:17 Absolutely. I don't think in the last 1030 years while I was in us, I was very self absorbed and busy trying to work with my nursing career and their bachelor's and master school. And I never felt like I have enough education, background and experience to work for the community. However, I know that the time will be coming for me to serve back to our tibetan community where our older generation has been serving as a board member. And it is always good to have a change in leadership and bring a different perspective. So I know that when I meet the right time, I do have to serve our tibetan community as a leader or as our colleague to navigate our community through these different struggles that we are facing. So I kind of really feel like I'm blessed because like the last, before electing for the board members, I participated as a parents committee for the Tibetan Children's School for the weekend program. We have a weekend program on every Saturday. So I was there all throughout the year in a fundraising event and I think that's where other parents saw my commitment and I really wanted to build a fundraising and help out our tibetan school. And after that I got elected as a board member and now I can truly serve my community in a bigger perspective and I do have a bigger audience. So I know that any small, big decisions I can make in collaboration with the other board member will help our community members too.

20:10 So what are your big goals? I know you have them.

20:17 My first goal is of course I want to complete my DNP because I am at the last friend of my doctor of nursing practice, which is very, very tough class, but I'm handling it. And my second goal is of course my family and the community comes together hand in hand. A couple of initiatives are we have a preschool that the tibetan preschool, we have only utilizing Saturdays. And I brought up issue that if there is a way to incorporate one more day, not just using us as a weekend and when our tibetan children, tibetan students, when they learn only tibetan culture and literature for one day a week, which is not enough when you compare to the other maths and English and social science there where they learn from Monday to Friday. So we were trying to pull up resources, brainstorming to incorporate one of the weekdays in the evening so that the Kate's have more access. And if in person is not, if in person is not applicable, if there is an online or some other access is available. The second thing is under me we have several programs right now, we are in the very, very early phase of planning. Tibetan Charter School, which is a project, will be coming in effect if everything remains successful and in a timely manner, probably in 2025, which will be a huge blessing for the tibetan community members as well as our american neighbors and community, because, of course, tibetan language is something that is not being spoken. And in Tibet, of course, our children, they are being forcefully transferred into chinese boarding school, and they are refrained from speaking tibetan language. So here, if we could provide a chartered school for the tibetan and the American, where they can learn tibetan writing and literatures and can apply those, I think our, especially our communities in Minnesota, will be really blessed. And this plan is not just for five or ten years. We are talking about like 30, 45, 50 years in a row. And that's, that's, it will, it will, it will bring up a new perspective for the whole Minnesota communities.

22:57 I just have to pause for a minute and say what a great vision. And. Yeah, and just to. You have a tibetan center in Isanti, right?

23:14 Yes, we have two centers, one in St. Paul and one in Asante.

23:20 Yes. And so that's very close to where I live. So it was so fun to visit with you that one day. Exactly. I learned a lot from that, too. So I'm just really proud of your initiative and you're looking forward. But if we could pause for a minute and reflect just on nursing, too, can you talk a little bit about how your perspective on nursing has changed, especially coming from India to here and what you've learned?

24:04 So the nursing education in India and their concepts and their experience in India at that time, when I graduated back in 2001, is very backwards. I remember when during my second year of nursing, I was involved in a project for polio eradication. So that concept, polio, was already eradicated in America, where I was involved. So as a part of project, we would go in slums with the polio drop, and we have a chalk. So we will cross each of the house. So just to make sure that we'll come back and check on those who did not receive the polio vaccine. And when. I also work in a community hospital in northern India, which was specialized in tuberculosis, remember, tuberculosis is one of the epidemic at that time. And tuberculosis is a chronic infection of lung because of the infection from the bacterial and is mostly available or prevalent in the low income family. So I was struggling with that. And when I made my transition into the US, whatever I have learned here in us, and the nursing experience in the hospital level was very diverse and very upscale. So I was working as a bedside nursing where I only thought, okay, I'm going to be following a doctor's order. But my role, my experience took a lot more. And there would be a time that I'm going through a patient's family history and updating it. There'll be times that I will making sure that patients have enough resources or shelter or living situation. There are many times that I'm doing education, and I know that nursing education to the patients are the most pertinent, even though, you know the physicians, they already have the education done. I remember when I was talking to one of the hispanic patients, and this hispanic patient has been admitted two times with hypoglycemia, and while he was driving. So I had the interpreter, and I knew that he already, by this time, he already had so much education done. So I told him, and I know that teaching to a patient with a different background sometimes requires a little bit explicit. So I told him that I know that by now, you have received so much education about the diabetes. However, high blood sugar can get NAQ complications with the kidney and stroke. However, low blood sugar can kill you. So when I mentioned that, I know that interpreter looked at me and when we left the room and she said, thank you so much for saying that out loud and very explicit, because I knew that patients from different background, sometimes they require a little bit of explicit and often less choice here. It's okay that you don't check your blood sugar many times, because if you think your blood sugars are high, however, if you don't check your blood sugar and if your blood sugar is low, that gonna kill you. So would you check your blood sugar because your blood sugar is not too low and that doesn't kill you. So I know that after leaving the patient's room, the interpreter thanked me. And that's the one of the things that I have learned. But I know that, in general, many of my patients with the american background, they have good health, literacy, that I don't have to be explicit. But there are many times that sometimes when they are making choices, I kind of give them, would you take a small risk, or would you look at the bigger outcome and the positive effect? So those are some of the strategies I kind of use in my daily nursing career.

28:31 I think that's very effective because you show, you don't tell, you let them make that. No, you let them make the decision, but you make clear to them the implications of both sides of the choice. That's a. Yeah, that's a very worthy skill. It comes in handy. Can you give other examples of how you do that kind of translation?

28:57 Yes. So I came across a young tibetan guy, late in fifties, and who had a stroke and a double stroke. And then he had a paralysis of one side of the body. And when I was talking to him, he told me that his primary physician never told him the importance of taking medication. And then that if he doesn't take the high blood pressure medicine, he will end up stroke. So I told him that. I'm sure your primary physician has told you in some extent, but what I was trying to figure out is how come that message wasn't related to him in a way that he understand, or he understood in a way that it is so important to take them. So when I see my patients with their different backgrounds, I see a lot of patients from ethiopian backgrounds, and I know that they have a different culture. I see a lot of somali patients. I also see a lot of spanish and few tibetan patients. So I know that when they have understanding of health, it's very different to the patients with the high health literacy. And I have to explain to them in a way that if this disease is coming, we have to make sure that it's coming, not coming from the depression or if it's not coming from this chronic condition, let's say anemia. So in a way that they could understand. But of course, I have to use my office hours in such a way that they could understand in a way, but also help them that some of these health conditions could not just from this disease, the anemia, it could be coming from the other perspective, like if there is any change of family stress or if somebody newly traveled to outside country or came back, if there's a new change in the traveling or a new change in the health structure. Health. Health structure. Like, you know, having a blood in the stool. So I want to make. I want them to understand that, you know, these are the consequences and could be consequences. And then that's why we are looking for different ways to see where the problem is coming from.

31:30 So, as an educator myself, I'm most curious what your recommendation would be for us in how we can. No, first, I want to underline how important this translation skill you have is, and then how can we generalize that to other students? And as an educator, I think you might have an idea or two.

32:01 So when I was in St. Kate's and I took a lot of course, from you, I, you know, I always appreciate you always willing to learn from your students and incorporating their ideas and there were many times that you directly asked me and put on, put me on spot. And I do appreciate because I knew that I always stayed behind in the classroom and I was kind of very introvert. But that also gives me a little bit because you knew you can already foresee that I will come in a position where I will have to advocate and take a leadership role. So that kind of helped me to get pulled or at least pushed. And then similarly, I think my biggest strength when I'm seeing patients is I'm willing to hear them out. And I think that my patients appreciate a lot. And when they give me survey, they again and again give me a positive remarks that I'm willing to listen because let's say even they bring a list. And when they bring out the list, I'm ready to go through this list and learn. But I often ask her, is this something that you are expecting to be treated for today or are you telling me because you wanted me to hear out? And a lot of times the patient wanted me to hear these health conditions, let's say somebody's going through depression screenings are very bad, very high up in 20, anytime, any above depression screening or 708, it's high or abnormal. So then I was interacting with patient and she told and she's already taking a medication for depression. So when I was hearing her and then I asked her if there is new stress in family. And she told me that her 23 year old is dealing with the Met addiction and the patient is in late sixties. And I told her that I am so sorry that this is your retirement age and you and your husband supposed to be enjoying your retirement, kind of relax and, you know, enjoy all these times that they have, you know, worked. However, now the patient and her husband is going through a whole different period. There is so much of financial strains, there is so much emotions, and there is so much chaos in the family that I may not have one measure to provide. But I told her that probably we can leave the depression medication at the same time. But then as our mother, I do understand that how important is for your Kate's to be there for your Kate's and not to give up and not, and continuously playing a role in your children's life. So I said, probably as a parent, you know, I can relate to her experience, but whatever she is going through is very difficult time and it's not normal. So during these times, she may have to practice a lot of patience, resilient. And then I'm always available through, you know, calling me through a nurse care line or sending a message through my chart and seeing how she navigates this process, then I also recommend if she could talk to therapists, because I think therapists can give you a very effective medium to express because these are the time that she really needs somebody to listen to. And the therapy can give her more, be maybe more constructive strategies where she can deal on the critical, critical and then delay the other that is non critical. So as long as I'm listening, I'm giving enough time to my patients, I think, and that's one of the positive attributes that I think they are appreciating. And I'm willing to follow this path.

36:23 That is a very courageous path to give patients space and grace and to stand beside them with the plan. But how do you deal with the administration and the medical industrial complex that says that this is not really worth the time, whereas you really know in your heart it is?

36:45 Yes. Yes. I know that as a business and hospital administrator, probably I may not be fulfilling my productivity. And I always came across back to my faith, my culture and my faith of buddhist philosophy to kind of, I may not be able to give them a huge solution, but at least I'm there to hear them out. And also empathy is a big concept that as a provider could apply and then ensure to the patient. So some of these my faith and buddhist philosophy that I have learned, like, you know, everybody long for happiness and nobody wants unhappy or sorrow. And that could be same in case of me. I want my productivity to meet. I want my boss to be happy. I want to make sure that I'm seeing as many patients as other providers. But if you look at the patient panel, there are many patients who are coming back again and again and again. And some of them are coming back again because of the new symptoms. And some of them are coming because of the chronicity or the complex health condition, let's say, with diabetes and high blood pressure and depression. So, and even if they come back, I think if I have to use the expert in the behavioral health, I will use that and I will provide that access to my patient. But I often remind my patient that I'm here to hear them out. And even though I'm not meeting my criteria, but I'm willing to lend my time to them. And that's why I think I have a lot of patients in eighties and nineties and 100. I often start my visit by, well, your birthday is coming out, and how are you going to celebrate? Or, you know, what are you doing this weekend? And kind of, even though they are retired and they stay home. But I think that kind of brings a little bit of excitement and new perspective to them and, or some of them will be like, oh, it's my 89th birthday. I'm not excited anymore. And I'm like, no, you know, 89 is a big birthday. You have accomplished a lot and all these years, so, you know, you have to make it special, even calling out all your friends or families. So I kind of bring that perspective and I think, and I, and of course, I like my older patients and I think they like me too.

39:53 I just have to say I really admire what you've done and wish that we could encourage other providers to make that stand too, that it's not just, I mean, if together we could all make a stand against production and money as the outcome rather than patient wellness and satisfaction and proceeding toward health. So can I have you precept some students? I have to ask.

40:35 Yes, at some point I do have to go through with my leaders and, but definitely because I'm very thankful to St. Kate's because, you know, my two years in St. Kate's I learned so much. All my professors from the first class that I took to the last class that was yours, I kind of felt really attached. And I know as a student and the student of St. Case and most of the nursing, they do struggle with finding a clinical site and I struggled with that. And of course I'm willing to lend my time and become a preceptor, but I also want to make sure that I want to precept effectively and I don't want, because there was a time when I was a student and my preceptor wasn't so effective and I don't want to give that bad experience. But I also think that being in a primary care or primary clinic, it takes years to build and I completed one year. I learned so much. I also feel like I have a long way to learn and incorporate these learning into practice. So I am willing to precept, but I think it might take another year or at least six more months.

42:05 Well, it seems like you've learned a lot from being a nurse. How would you summarize? Kind of what are the lessons that nursing has taught you?

42:16 So my concept with learning was very small, very minimum. Back from India to now practicing as a APRN and nurse practitioner when I'm taking an active leadership role. So applying nursing concepts in India and following the doctor's orders has changed so much to self learning. Right now in the APR enroll, collaborating with the specialist or radiologist or other internist and how to apply those learning in a way to a patient that is cost effective and then that doesn't give false assurance, but also it's not our, doesn't bring too much cost issue to my patients. Let's say my patient, I prescribe an inhaler in that. If that inhaler costs that patient $400, I understand that my patient in sixties, they have a limited income and that $400 could be a payment of their groceries. So I know that I need to collaborate with somebody to look for an alternative inhaler. There's no way somebody should be spending inhaler $400. And I know that my older folks have really limited income and they shouldn't be spending $400. And so a lot of our collaboration, a lot of learning and then applying those learning in a way. But one thing that I struggle after, the COVID is our specialist are still behind in seeing patients. So like, let's say rheumatologist, that's one of the specialists that health partners had struggled and they have put that as a priority. But I have many patients who needs to get back into the rheumatologist appointment for their medication refill. So I always give them assurance that as long as they are on the schedule, I am willing to refill those medications and help out during the transition. So whatever I'm learning and also understanding that during these times, access to healthcare is tough. And if it's access to healthcare, seeing me versus specialists, it's tough for the patient. So I want to make sure that we use that time in a constructive way and address what is on the table at that office visit and also like a future implications and future refills, that how I can help with them.

45:07 So if I hear you right, you're saying that you've experienced increased stress in your position because of the unavailability of specialists and that that has changed your workload and the way that you approach what you've been doing. Are there other changes?

45:32 No. I think getting back to the specialists not only affected their health partners, but has affected many healthcare organizations after the COVID and patients not able to get back to the, let's say, dermatology or dermatologist, aura rheumatology, or GI. So, you know, patient with, let's say, dealing with the IB's or irritable bowel syndrome, they need to get back to their schedule and see how they are being managed and treated or what's the next step. So these are the, these are the areas that my patients have struggled again and again, and so did I. And, you know, I kind of willing to, as long as their insurance is accepting any external counsels, I told them again and again that I'm willing to change the referral, and then I'm willing to help them out during the transition if it's refilling medication or ordering a lab or getting in touch with the specialist team.

46:41 I'm going to change the topic a little bit now to one of collegiality. You've probably heard the phrase nursing eat their young. Did you have an experience of being shunned, sign, lied or gossip about in the nursing profession and how did you handle it?

47:05 So I believe that. I really believe that nurses eat the young. And I. My 13 years in Henbig county was very difficult, and I started as a bedside nursing in a float pool, and float pool is one of the department where you are trained in multiple different department and nursing units. So coming as a float pool nurse and kind of adapting to work in intensive care unit or cardiac flow is never easy. There were so many times that I was either shut off, shut off or laughed off because I didn't do the, let's say, feeding tube or Ng tube placement correctly. But I don't. I think I left that moment to, you know, put me down. I kind of went back to my nursing procedure and try to see what I didn't do correctly, or I would pull aside that nurse who laughed at me and I would ask her what steps on nursing process that I didn't do it right. And I always tell her that I'm coming from football, meaning to help and supplement and aid your flaw, and it's their job to support me. But at the same time, if I'm not following these nursing procedures right, she could stop there and then help me correct, and then I would learn in that way and then apply that, the same procedure on a different patient in a lot more better way. But it is true. But I don't think. I've never let anybody kind of put me down. I may have cried one or two, but like I said, my nursing journey, it's not like any other nursing journey. It has been from the beginning. It has been very tough. Learning exams. Everything has been tough. So I have that resilience. I have that humor. And I kind of come from the very lowest perspective. I knew, I already knew that there will be some kind of bias and kind of ferbarism. So with that and then also being in a floor pool kind of taught me a lot because when I get to the floor. I have to come with the best nursing personality. I have to make sure that even the floor nursing assistant willing to help me, and I could, you know, come approach them in the best, pleasant way, and I could get all my stuffs ready, and I had to just get in their time. That taught me a lot of humility. And then I knew that I'm not their own floor nurse, so I have to be better and be more attentive to the coli. And then, of course, timely medication because I may be criticized more because I'm not that floor nurse. So that kind of gives me a lot of a good, solid foundation, and that's how my career was built in the last 13 years.

50:32 Well, I just have to say this. I have a lot of personal admiration for you because I've seen you show grace and resilience under pressure, and I admire that. And it's been an inspiration to me to, to see you do that. So thank you for being that role model. The sisters St. Kate's was founded by the sisters of St. Joseph on the value of love the dear neighbor without distinction. How have you been able to live this value out through being a nurse?

51:09 I think that concept coincides with my faith. The buddhist philosophy believes that all living beings want happiness and nobody wants sorrow. So despite differences, despite health literacy difference, or economic or social background, I know that all my patients, irrespective of their background, requires same time, same treatment and same experience. There were many times that, let's say, for example, let's say a patient's going to have a right hip surgery in the few weeks. And I often take enough time to explain the patients with the different background that it's almost that the surgery never gives you time. I don't want them to feel like they are the one who wasn't given a time. And I said, this is very common because or has a way to strategize and prioritize surgery. You will be informed two or three days before. I always take time. And then let's say my hispanic patient is about to get discharged. And this discharge process in the nursing or hospital setting can be very overwhelming. They could be delays from the nursing point. They could be delays from the pharmacy point. They could be delays from the physician, because let's say this physician is making round, or let's say physician make round. And now in the OR, and the physician didn't get time to put in discharge. So I want to make sure that, you know, I visit my patient often and give them reassurance that you know, the discharge process can be overwhelming to us as well as them and the providers. And we want to make sure that discharge is carrying out in a good term. And all the treatments and follow ups are correct and the patients also get the, the correct discharge instruction. Those are the very small things that I kind of exercise at bedside.

53:34 I think those are very big things because in a way you outline how we treat people in such a process. You're telling them this will happen then, this may happen then. And that's very reassuring to patients. But it's also one of those things that has really changed about being a nurse over the years. So what do you think? How do you think nursing needs to change as we become more bending toward technology?

54:09 Yes. So technology or electronic medical record has integrated so much, I think in like year 2000. And it was criticized again and again by providers, nursing facility nursing. And then, you know, the other health professional. However, you know, change is part of our society and change is often difficult and brings out a lot of hesitation, nervousness. But if you look at the change, there is always a positive attributes impact. And change also brings like, let's say like changes next few years improvement. So my biggest struggle was when I was newly nursed. The EMR came into at that time, electronic medical record Washington not fully transformed. And it was in the process of changing. We were using the medication scanner barcode, which wasn't working too greatly or wasn't too integrated into the medication documentation. There was many struggle. The healthcare professionals or the leaders gave us enough education and we kind of adapt with those change. However, I think the compliance often were a big issue in the beginning, but then we had bigger transformation changes like, let's say in hospital we use medication, even report form. And these are the, I think these are really great changes that kind of help to track because in healthcare there were so many events that medication, even errors are occurring in bedside or, or let's say operating room or the recovery room or other departments. It's very important to study these changes in a study these changes in store and then use those data for analysis in a way that can project and help for future learning. I think these are the. And then because of those data, it also help for the statistician to project future changes or future implications or how to improve in our nursing world. I think the biggest change in nursing is discharge. There were so many changes done with discharge and the biggest chaos was sending medications from pharmacy to the unit, which usually can take few hours. So within this transition, the nurses can be busy with other patients and not able to look at the status and the floor that I worked in as a charge nurse takes an active role to make sure that the control substance prescriptions are run down in a timely manner, which eliminates extra 45 minutes. And then the pharmacy makes sure that they add communication in the epic or EMR that alerts the nurse that during this to this time, like two to 230, the medication discharge is ready and can be picked, or if the medication is too big to send us to the tube where somebody could go down. I think these smaller, small changes have helped the nurses and the nursing process that also helps the patient patient too. Another thing is the admission process. So patients waiting from Erde to the nursing floor. Back then, we used to wait for 20 to 30 minutes for the ER nurse to call you and give you a report. And there is so much nurse, this redundant job where the nurse is busy with some other patients and the ER nurse kept calling and that delays the patient admission, also blocks or pulls the patient ER. And the ER is not able to take more patients where Erde should be a transition flow and should be able to transport out the patient fast. So there was changes in the nursing that we will not get a report from ER because the EMR gives us very good illustration of what happened in ER and that we use those documentation to help understand the patient. But the only changes is applied to the med surg. But I know that the ICU, when the patient stands from ER to ICU, they get a phone call, verbal report, exchange. So these are the small changes that I have seen during my nursing process. But I know that it helped a lot for smooth patient transition and smooth patient transition from ICU to out to the units, so that it will open up more bed for other patients.

59:40 So a lot of process changes, is what I hear you saying. No wonder you focused on a process change for your DMV project. Something very familiar, something I hear underneath all of your talk is how your being a Buddhist has impacted your care. Can you elaborate on that?

01:00:05 So, buddhist philosophy has a very simple meaning, and I'm not that religious person, but I do share a basic buddhist philosophy, the motives, the intention, and the happiness. And when you apply these small concepts, like, let's say, if I'm helping my neighborhood in a small test, I should be helping in that way that I'm not expecting a return of favor. So if I have that intention, that, okay, I'm helping my neighbor in this task, and then, in a way, in return, I'm helping a return favor, I may be disappointed, because if my neighbor didn't help me back, I would be really disappointed. So, same thing. When you take that concept in nursing, you help your patient in a way that, not just because you are fulfilling your time, not that you're fulfilling your duties, but let's say if you are explaining to 80 years old in a way that your patient understand, and then imagine your parents. My parents, my father is very old in eighties 89. And if he is getting discharged from hospital, I want my nurse to sit down and explain in that way that he could understand and then make a very simple example and then integrate those changes in his daily living because his schedule at home may be different from other, somebody else, a different patient's schedule. So these are the things that this philosophy that I have used in my nursing career and buddhist philosophy also believes in helping somebody in need and not in a way that you are not expecting a return back. Or let's say I'm helping you because I know that I'm gonna build a very good deed, not in a way, but helping that person in a very kind motive and nothing, a return favor, and then treating all your patients in a way that everybody, even small insects and animals, they need happiness. So I apply these basic buddhist philosophy with my patients in a way that, you know, I apply these basic buddhist ideas in my nursing practice. And, you know, I try to stay true to my motives and my intention so that if I'm helping another, older patients, I'm hoping that somebody will, you know, help my patients, help my parents in a way that, you know, they could understand. So that's, that's, that's one of the idea.

01:03:07 You know, what I'm so impressed is that you've kind of married it in a way that's very, very integrated, and I can see where that's quite meaningful. But what sustains you in doing this very difficult work?

01:03:24 Yes, exactly. But, you know, not necessary. I'm always following the, you know, the buddhist philosophy or let's say nursing. There will be times when I'm more tired, I'm more discouraged, but, you know, but I take some days, I may be taking one day at a time and then kind of dealing what's in front of you and less worrying about the future or what's the agenda on the next day. And then that also helped me carry out my daily activities.

01:04:00 Yeah. Focus on what's in front of you.

01:04:04 Exactly.

01:04:05 And go slow. So one last question. What's the most fun you had being a nurse?

01:04:17 So, you know, nurses in America, it's a whole different world and perspective, and you have a way to achieve highest goal, which I have never intend. And if I am, let's say if I'm still residing in India, probably I'm still exercising the same concept that I have learned in bedside nursing, which is not wrong, which is still good. But here, I have never ever thought that I will be taking masters and now taking DNP and. But I'm actually taking the DNP class, and I have completed masters and person like me, which is such a late bloomer, which everybody tells about. If I have gained this momentum, I know for sure that everybody else can weigh overachieve, because a person like me, who is very slow to learn, very slow to adapt, very slow to, you know, get, adjust. And I have learned and come up to this level, which is still. I'm still learning. It's not like, you know, I learn everything. I'm still learning every day when I see my patients, I'm trying to use a best bedside strategies to understand them, help out in a way. And then in my clinical setting, I'm trying to learn as day goes on. But I've never, ever imagined that I would reach at this point where I am and nursing, it's an art. I can always go back. You just come with different tools. And these tools can be not just built overnight. It built with your background, your culture, your faith. And now our patients with the different backgrounds, they should have those advantages so that they could get to the. Their health outcome or let's say, controlling their blood pressures, let's say hitting the right a one c or glucose control, you need to bring those tools. And Minnesota basically is very gifted with all these health professionals from different background because our patients panel are changing, and we need to come up with strategies that can align with the patient's culture and their disciplines and then their routines. So I think being a part of healthcare in Minnesota, and, of course, I feel like I'm very lucky.

01:07:07 It sounds like you, to put it in nursing foundation terms, it sounds like you are flourishing. And what you're also doing in this growing, this human flourishing, is you're helping your patients to steward their own health, no matter what their background or culture is. So I am so grateful that you have shared your story with us. And I can't even put it into words how wonderful it is. So thank you, Tenzin.

01:07:42 No, I personally want to thank you for being my mentor during my master's school, which could be easy for the other american student. But for me, it was like climbing out Mount Everest. I wasn't gifted student. Writing a grammar sentence was even hard for me. And then learning those nursing philosophies, the reflection, the ethical, the ethic class, it was all new to me because I was relatively. It's a new school, and learning in us was a whole different part. But I think you just pulled me and you gave me. You have shown me interest. You gave me a little bit of mentorship, and I kind of felt that bond, and I knew that I'll be always entheptic to you. I know I had many professors, but you have shown me that mentorship. And I think based on that interest that you gave me, I think it builds on very slowly. Initially, I was very hesitant. When you pull me and spot me in the class, and that gives me a little bit of a. Gives me a platform to talk, and I'm talking in front of, like, 40 something students, and after class, I'll be nervous, like, what did I just see? But I think you knew, because you knew that where I was coming from, very introvert. And now up to this, being a nurse practitioner. And I really thank, because I know that deep down, you have shown that interest, and I'll be grateful. And I know that you had done that to many students, but I always felt that very special connection, and I will always be.

01:09:33 I am very, very grateful for what you said, but I won't ever forget. I remember one of my patients really liked you. Do you remember that? And he came to me and he said, I think I'm going to trade you in for her. So then I knew you were a winner. I knew you could be a leader. And it wasn't me that made the judgment, either. It was my patients. They knew that. And so I was so grateful also for the time that you spent with me. And I think we better call it to an end, because I need some Kleenex. Okay.

01:10:19 May I ask one question?

01:10:21 Tenzin.

01:10:21 This is going to be. This will be in perpetuity. We'll always have this recording. Is there anything that you would like to say that maybe something either to your family or something about the profession, or just anything you'd like to add? Yes. I think my message to my family, my community, and my friends. I think my families didn't know that. I gave them a hard time during my boarding school, and I transitioned. I wasn't as gifted. However, they always gave me some time and space and for me to grow. And as for my community, I have not been actively participating and helping and volunteer. However, I am meeting now. I am able to volunteer and help them out and be active part of community in different ways. And now at the primary care, a lot of patients gives me trust, provides me trust and respect. And I'm really humbled for that because there's no way that my journey, starting back from India in a refugee camp to where I am right now is all gifted by my friends, family and community. Otherwise, I don't think I'm in the spot where I am right now. Well, thank you so much. It was a delight. And I'm going to end the recording right this moment. Thank you so much.