But you have been taught the theory behind it right?

2014-03-13 11.13.02

(Wall mount within the Stavanger Acute Medicine Foundation for Education and Research aka SAFER)

One of the main things I wanted to look at when I came to Norway was the difference/similarities between the clinical education content/delivery to that of my own Univeristy. Since I started my nurse training I have been very interested in the comparison of skills needed for practice in the real word, and those taught within the program of study. I personally feel that they do not correspond to each other, and there is work and progress to be made in bringing undergraduate nurse education more into the 21st century.

While many may argue that nursing is an art not a science, I would beg to differ that it is in fact very much both these things. As once described and explained to me by a lecture that I very much admire at my University; with all the good graces of a nurse being kind, caring and compassionate (which I am not dismissing in the slightest they are essential in the profession), those things alone are not going to be able to settle a patient who is attached to a cardiac monitor which starts alarming and gets upset, alarmed or anxious without the nurse being able to interpret the monitor and explain why it may be doing what it is with the sound background of anatomy and physiology in that area. Or in pediatric nursing, how would a nurse explain to parents or the child themselves why they were receiving a certain medication or procedure. It is not always the doctors that are asked the questions and the nurses are often the most available source of information for patients/parents and next of kin. A nurse cannot always keep referring the questions to the doctors. Though of course nurses need to explain and work within the ream of our profession and sphere of competence, they cannot start offering out tip bits of information without the necessary qualifications. Our duty of care extends to ourselves having sufficient enough and up to date knowledge to care for our patients in the safest and most excellent manner.

In Norway one of the things I noticed first is that nursing students here are expected to learn and carry out cannulation in their second year. In the UK this is something most qualified nurses cannot do as it requires you to take an extra training package while you are working. This includes the need of supervision, which given the current climate mostly only doctors and phlebotomists can provide. The time they have to spare in not in great quantities. When I spent some time in the accident and emergency department here in Stavanger, the nursing and medical body were equally surprised that not only are we (as nursing students in the UK) not taught cannulation, we are not even taught the theory in our training either. One of the doctors was very quick to jump in and ask when we then did our cannulation training and I explained that it was not even mandatory on qualification. The puzzled and confused expression in their face more or less said it all. Here in Norway the majority of doctors do not cannulate (they have the option to learn but it is not mandatory), it is seen a nursing role. I have seen the benefit of nurses being able to undertake this skill on the wards as well, as when we are administrating antibiotics for example, and the cannula is not working, or has been removed. There is no time delay or hesitation in it being replaced and the antibiotics going through as the nursing staff can immediately put one back in. Treatments are not delayed, and from my experience in the UK, if a cannula is not working, it is often very difficult to find someone to replace it quickly. This means antibiotics and other medications are delayed and this may have an impact on the effectiveness of the prescribed treatment. I am by no means qualified to state that allowing and teaching nurses within their undergraduate training to cannulate would make the treatment for patients more effective and successful, but you can see the logic and the argument in the implementation. Nursing students here are also able to carry out male cathatrisation, another skill that nurses in the UK can only carry out on qualification with a specific training package.

Simulation training is used a lot more in undergraduate nurse training here than that of the UK. In the first month that I was in Norway I visited Stavanger Acute Medicine Foundation for Education and Research (SAFER) which provides simulation training to nursing students along with all emergency service personnel including the off shore workers on the oil rigs. There is nothing really of this size in the UK though Bristol is home to the Bristol Medical Simulation Center (BMSC), which offers a similar service. In Nottingham, simulation training is not used prominently in undergraduate nurse education, however there is talk that it may be introduced.

In my visit I joined a simulation lesson with other Norwegian nursing students and we carried out a basic refresher of CPR and the use of defibrillators. Afterwards we were split into two groups and put into a simulation room with one of the facilitators controlling the sound/movements/clinical condition of an electronic dummy that was laid out in a mock ward environment. We were fortunate enough that the educators and the majority of the other nursing students had good enough English to be able to attempt the simulation in English! There is a lot of research and studies being published at the moment which look at the use of simulation training and its benefits/suitability to nurse training. So far, much of the research would suggest that simulation in nurse education is beneficial in terms of increasing confidence, transitioning between theory and practice and clinical skills competence. Tough there are still questions which lie around simulations suitability to improving actual patient care. Its use however is on the increase and a number of reasons could be sited for things including a decreasing availability of placement areas and an increase in student numbers, the variations in competence in communication, administration of medicines and decision making among nursing students as found by the Nursing and Midwifery Council (NMC). Finally the increasing challenges nursing educators face in developing and  preparing students for the real world of nursing practice the variety of placement/clinical training opportunities available (which can impact on students exposure to certain environments and situations like acute and deteriorating patients), are other reasons that simulation training may become more prominent in future training.

It has been announced recently that there is going to be a review into undergraduate nurse education in the UK. Health Education England along with the NMC are to launch the `State of Caring Review´ in May this year lead by Lord Willis. It comes after the Francis Report highlighted concerns with nurse education and training. It will be interesting to see if the final report which is to be released early 2015, will consider or report on the clinical skills education and delivery along with any mention of need for increased simulation training.

 

 

 

 

 

 

 

 

Beyond registration

DSC00269

(A view of pulpit rock, one of the main tourist attractions just outside of Stavanger. The views were incredible, 604m up tends to allow for that)

While the main focus of this blog has been undergraduate nurse education, I have found it interesting to look at the opportunities available to registered nurses here in Norway as well.

Often when choosing a career you consider what progression is available and what sort of opportunities and options are open to you within that career. One of the reasons I wanted to go in to nursing was the sheer amount of opportunity and learning continuum that the profession provided. I was not going to be constricted to one working environment (consider community, hospital, prison, military among others) and the clinical/leadership and management options provided you with the ability to mold your carer and aspirations with new experiences and interests. This variety also allows for a wide variety of personalities and characters within the profession itself, while still maintaining the underlying principles of care and compassion to create a dynamic and passionate workforce. So would this be the same here?

In Norway the band system of 5/6/7 and beyond does not exist as we have in the UK. In fact there isn’t a noticeable structure at all. There are ward managers and below them are assistant ward managers but nothing noticeable. The ward I work on at present has three assistant ward managers who take on similar duties and responsibilities that our own band 6 nurses back in the UK would hold. With this status comes an increase in pay and a absence of night shifts. It is a simple application process when a post becomes available. Everyone wears exactly the same uniform from newly qualified to ward manager. Even the non clinical staff will wear the same white scrubs. The doctors to distinguish themselves slightly will wear a white lab coat over their white scrubs. The does somewhat eliminate the hierarchical structure that is often, or has at least in history, dominated nursing within the UK. Personally though I like the alternative uniforms as it allows for staff, patients and visitors to distinguish from each other and it does give you a certain pride with identification.

I have already mentioned in a previous post that nurses here are trained generally and do not specialise in pediatrics/mental health/learning disability until 2 years after they qualify. After that they are able to take on a MSc in one of these specialties or in something like health and safety or management. These are full time courses run by the University of Stavanger, the fees are paid for but you lose income as you are unable to work so this may not be the most viable option for nurses, especially those with families.

There is another option however. After 2 years of practice experience nurses here are able to start undertaking a clinical specialist qualification. This is a part time qualification which is done in a nurses own time. It is run by the hospital and comes in three levels. A nurses pay will increase in small amounts with each level. This qualification was introduced to aid in nurse retention, allow for nurses to further their knowledge and skills which overall would help to provide a higher quality of nurse. There is no portfolio/or re validation requirement of nurses here. A few whom I have spoken to feel that this would be a good idea and wished it would be introduced to encourage skills to be kept up to date. The levels for the clinical specialist qualification are transferable within the hospital and to the community, but to move hospitals and still keep the same pay level and status is more at the discretion of the new ward manager and the human resources equivalent. Details  of each level are below:

Level 1 –  Available after 2 years of clinical experience. 1000 hours of reading around the topic of general advanced clinical nursing practice, computer based tests to assess knowledge on areas like nutrition, infection control and health and safety.

Level 2 – Available after 4 years of clinical experience. 1000 hours of reading more specific to your own specialty of advanced nursing practice e.g. cardiology, trauma and orthopedics, neurology. More computer based tests. Level 1+2 are evaluated by the hospital.

Level 3 – Available after 5-6 years clinical experience. The reading hours are increased and there are additional study groups put on by the University (this level is evaluated by the University as well as the hospital). Nurses are also required to write a paper on an area of their choice within their specialty. The salary for level 3 is the same as a specialist nurse, so one that has undertaken one of the 2 year full time MSc. There are not many of these Level 3 nurses as only a couple of applications each semester are allowed.

The title ‘clinical specialist’ is a general one rather than specific as we have in the UK such as a diabetes or tissue viability specialist nurse. All levels are moderated and marked. Level 2+3 also have mentoring requirement. This can be for peers or students.

With reference to mentoring, all nurses here mentor students. You can do a 2 day course held at the University but this is not compulsory and you can mentor a student without it. There is no yearly update as we have in the UK, certainly in Nottingham. Each student will have two mentors, one primary who will sign off any documentation, and the other if the primary mentor is unavailable for a shift. Students are assessed at a pass/fail and they have two attempts to pass. Students need to write evidence of what they have learned and reflected upon including a care plan about one patient. It is a lecturer and mentor who go through the paper work.

There are not any specific preceptorships available either for newly qualified nurses that I have found here, were as the UK is seeing a growing increase in the number of specific preceptiorships offered including rotational programs. So far I have established that newly qualified nurses could expect a few weeks of orientation and supernumerary status. This may change in different hospitals however.

To draw this post to a close, there was an attempt at introducing something similar to an advanced nurse practitioner (ANP) in A+E , but from talking to nurses who work there, this seems to have trickled out. One of the main reasons seemed to be that people just simply were not going for it. So far my research has not highlighted any areas of nurse consultants, though you will see alcohol consultants which can be a nurse or a social worker who has taken an additional course to train in that area. Not though to the level that we are beginning to see in the UK.

With all of this in mind, I do look at the two structures of the profession and working environment and wonder if I would have been as happy working here as I would in the UK. They certainly have their differences although the principles surrounding nursing are exactly the same. Though I am not initially sure  a grand total of 3 months allows me to make a well informed decision but first impressions would suggest that nurses in the UK have a certain degree of freedom and growth that suits me a great deal which is not translated quite as well here.

 

 

 

 

 

Every cloud

2014-03-24 07.10.58

(a view of the hospital on my way to work in the morning)

It has been a while since my last post but I figured I would wait a while until I had got into the swing of starting placement before I started rambling.

So Is it what expected?

No

When I was choosing which country I wanted to apply to for the Erasmus I choose Norway primarily because it offered acute and emergency placements. This to me says very medically/surgically ill patients and a fast working environment along with pressure and a high demand for the workforce to be on its toes. I like that, and I thrive off of it. So it was natural decision.

The reality…

On OBA (translates as the acute treatment and observation ward) It is safe to say that there is a much slower pace of things over here. However, I do not necessarily put that down to the nurses working at a slower place, there is simply far more of them per patient than there is here. 1-4 in the daytime at most and at night it may increase to around 1-8. The majority of the patients are self caring and I have needed to do very little to no personal care at all. Something I confess to missing. The ratio is great and I have rarely if ever so far seen a nurse pushed for time or attention with their patients. I am simply just not used to it.

The one thing that has surprised me which I did not foresee as being as much of an issue as it has turned out to be initially was that of the language barrier. Don’t get me wrong, a lot of the staff speak English and my mentor is fantastic for translating notes for me and helping to me to understand doctors rounds, however it is the huge barrier with patients that it has thrown up. Looking back I am not really quite sure what I expected, there are some patients who can speak English, if they are under the age of 50 then you have a good chance of being able to have a conversation. But, generally I feel like a bystander in patients care, unable to get fully involved because I cannot explain things to them independently without a translator and if I can see a patient is very distressed or unhappy it is much harder for me to try and alleviate that. It has frustrated me hugely and for me it feels like I am unable to care ‘properly’ for people. An interesting discovery as it made me think what caring for someone actually meant to me and what it entailed. My independence in my eyes as practitioner has also taken a slight nose dive.

This particular discovery has made me look at communication in the way the universities always want to try and get through to you but never quite manage with the endless communication lectures and essays, because until you are in a situation where you cannot verbally communicate, only then do you realise its significance, value and presence in the care of patients. Or so this is my opinion anyway. I had certainly taken for granted how much I relied and invested in this within my own practice.

The communication barrier also through up another interesting discovery for myself. I very quickly learnt that I do not like not being able to understand and interpret my environment. It is the most unnerving experience. Patient notes, posters, signs, doctors rounds, general chit chat and conversion in the staff room, a complete mystery without the aid of someone to translate or google at your disposal. I have no shame in admitting that I found this really hard to deal with. It is incredibly isolating. However, for the first time I was able to feel what it was like for those patients that I have cared for that do not have any understanding of their environment or who cannot communicate, dementia and stroke patients among others came to my mind. It is frightening and I have gained at least some empathy with this that I didnt not foresee arising. With this realisation came a note of sadness as well, as I appreciated the loneliness of the situation. With this knowledge now in hand which I endeavor to take with me when I return to the UK, I hope and intend to improve my own practice care for those patients were communication is a barrier.

That aside, one of the other mot notable things that I experienced so far is the amount of mental health nursing that is required here. Unbeknown to me when I arrived, OBA is actually the designated ward for anyone who has attempted suicide or has simply drunken way to much alcohol and has needed to be hospitalised. And it is unfortunate to say that is is a very frequent occurrence. The amount of people coming through the doors with paracetamol overdoses and other means of attempted life taking is heartbreaking. There is rarely time I walk onto the ward and do not see some one being put in line of sight because they are at risk, and the ward itself is usually at least a quarter full of alcohol intoxication. I myself have had to sit within line of sight of someone on varies occasions. My exposure to mental health within my own practice so far has been very limited as we are not given a specific mental health placement, so I am taking this one as so. I have asked the nursing staff why they think there is such a problem with suicide and alcohol and they have said that generally they feel its down the the pressure from society to make something of yourself and be successful. The high cost of living is an added pressure. Patients will get transferred to OBA as well from the psychiatric ward if it is suspected that there is also something more significant medically wrong with them like a heart condition which needs investigation or monitoring. Patients with personality disorders and bipolar again among others will be brought over and the nursing staff will need to care of them as well. Something in this situation which does make the nursing care easier is that face that nurses are trained generally here. And that means they have specific mental health training in their undergraduate years which equips them far better to be able to cope and care for these patients than if it was the UK (granted that may be a matter of opinion). I have always felt that undergraduate nurse training needs to have more varied scope of placements to include in particular mental health as a mandatory component. I do not see where I would have got the exposure and experience of working within mental health if I had not come here. With its prevalence in our own society, I do not see how it can be excluded. This I have to say is not a generic situation as I believe there are some universities which do give their ‘adult’ nursing students mental health experience.

So despite this so far not being what I had anticipated or expected, and feeling somewhat a few hundred miles outside of my own comfort zone, every cloud has a silver lining and I am readjusting my outlook. This Erasmus is bringing me a lot more personal challenges that I had predicted.