VOL: 97, ISSUE: 22, PAGE NO: 38
Lynne Wigens, MA, DipN, CertEd, RGN, RNT, is assistant director of nursing, West Suffolk Hospital, Bury St Edmunds
Cathy Ryan, MEd, RGN, DN, is senior lecturer, School of Health, Suffolk College, Ipswich Hospital, SuffolkClinical areas, both in the public and independent health care sectors, need clinically effective, cost-effective nurses and midwives who deliver an appropriate service that meets the needs of users. Increasingly, health care must be more proactive: the NHS agenda offers opportunities for nursing to expand care boundaries and this requires a flexible workforce (Department of Health, 1997; 1999a).
Clinical areas, both in the public and independent health care sectors, need clinically effective, cost-effective nurses and midwives who deliver an appropriate service that meets the needs of users. Increasingly, health care must be more proactive: the NHS agenda offers opportunities for nursing to expand care boundaries and this requires a flexible workforce (Department of Health, 1997; 1999a).
This is set out in The NHS Plan (DoH, 2000), which includes the requirement that additional nursing staff are 'fit for practice' (UKCC, 1998). International recruitment can go some way towards meeting this need, although a broad span of activities to aid recruitment and retention should also be used, such as return-to-nursing and flexible retirement incentives, and improved work practices.
The past decade has seen preregistration training places for nurses and midwives cut: for example, between 1992 and 1995, training places fell by 28% (DoH, 1999b).
A short-term solution has been to recruit nurses from abroad, with a consequent rapid increase in foreign nurses coming to the UK (UKCC, 2000). Provisional statistics from the UKCC show that 7,361 foreign nurses and midwives registered with the council in the year ending March 2000, a 48% increase on the previous year. Inquiries from potential overseas applicants have risen to about 1,000 a week (UKCC, 2000).
Despite the employment of additional staff by the UKCC to meet this increased administrative burden, some applications are put through a fast-track system that involves sampling 2% of information transcripts for recruits from 'certain countries' rather than vetting every single one.
The UKCC insists this will ensure that standards of quality are maintained (UKCC, 2000). However, the implication of this decision is that potential employers may need to implement robust processes to ensure the effective personnel tracking of foreign recruits.
In many cases the UKCC recommends that a recruit undergo a period of adaptation training before registration in the UK. In practice, many applicants complete an adaptation programme lasting three to six months, a period determined by the UKCC in each individual case.
The framework for this adaptation period should incorporate an assessment of the applicant's competence to deliver safe and effective care (DoH, 1999b; UKCC, 1998). And the placement for this period should provide a sufficient range of experience to meet the competencies of a registered nurse and must have the relevant ENB approval for student placements (ENB, 1997).
If this is not the case, it could lead to situations in which foreign recruits are placed alongside nursing students from higher education institutions, but where local educational providers are not involved in the adaptation programmes for the overseas nurses.
We believe that the current number of international recruits could lead to a heavy teaching and assessment burden for RGNs and that a coordinated strategy involving partnerships between service providers and educational providers is vital. This includes partnerships between institutes of higher education and health care employers, as well as between practitioners/mentors, lecturers and foreign recruits during the adaptation programme. The model used in our setting requires the implementation of such partnerships before the nurses arrive.
A settling-in period for foreign nurses (usually three to four weeks) is useful and should include an introduction to local facilities and amenities.
During this time statutory in-service training, to acquaint the recruits with their placement area, will also begin. Nurses on the adaptation programme attend an induction at the higher education college at the end of their settling in period. Although the employer will undertake a clinically based teaching approach, the institute of higher education also offers four study days, which nurses are required to attend. The four study days cover:
- Professional and ethical practice;
- Care delivery;
- Care management;
- Personal and professional development.
The study days are spaced out over the period specified by the UKCC in relation to each individual. In a safe environment, away from their practice area, the nurses can discuss and debate practice, research and care decision-making, and appreciate cultural as well as nursing differences.
The nurse is assessed via a learning contract - based on the registered nurse competency framework - which is negotiated between the nurse and his or her mentor/assessor. Successful completion of the various stages is shown through the development of a portfolio that provides evidence of growth and achievement, and collaboration between practice and education (Wenzel et al, 1998). In recent years, portfolios have been accepted as a mode of recording knowledge embedded in practice that is often difficult to describe but represents the expertise of the practitioner (Jasper, 1995).
Specific learning outcomes are translated into a range of activities. The overseas nurse may already be undertaking these activities, or intending to do so during the adaptation programme. The evidence to be provided for each activity is discussed and the appropriateness of various forms of evidence determine what evidence will be required. Examples that support the attainment of learning outcomes include records of observations, care plans, critical incident analysis, teaching packs, student evaluations of learning, audits, reviews of research and reflections on implementing research evidence in the area of practice (Table 1).
Two copies of the evidence are prepared before the programme outcome meeting - one for the mentor/assessor and one for the nurse lecturer because these portfolios often take time to review. The higher education institute can retain one copy for external review.
This approach helps the foreign nurse to develop a professional portfolio to meet PREP requirements. The evidence, which is collated, can demonstrate innovation and creativity in their approach to presenting their clinical work.
The purpose of the programme outcome meeting, which is attended by the nurse, his or her mentor/assessor and nurse lecturer, is to provide the nurse with feedback and determine whether the registered nurse competencies have been achieved. Prompt feedback and confidentiality are important aspects of this process (Wilkinson, 1999).
The tripartite programme outcome meeting is perhaps the strongest part of the mechanism that aims to ensure that the RGN acting as the mentor/assessor is adequately supported in making the critical decision to allow the foreign nurse to obtain UK registration. Verbal feedback is reinforced in writing.
From a pragmatic perspective, the adaptation strategy outlined above has financial implications in terms of time and staff.
Mentors taking part in this programme are advised to have an ENB 998 teaching and assessing certificate or other valid teaching/assessing qualification and are not expected to support more than two students at the same time. The number of clinical colleagues who meet the requirements for this role and are available may mean that it will have to be re-evaluated in future. The involvement of nurse lecturers in the assessment of practice may be considered unnecessary as it is not a UKCC requirement.
Foreign nurses may not have encountered this form of assessment in their home countries and could perceive the openness of the assessment process as a threat. However, those who have taken part so far have found it a reassuring and supportive partnership.
Despite inherent disadvantages, the potential advantages of this form of assessment outweigh the drawbacks. There is a clear and demonstrable integration of theory with practice, allowing the assessment process to reflect more closely the realities of clinical life (Rolfe, 1993).
Basing the learning contract on current clinical practice ensures that nurses are suited to work within the new culture, with the skills, knowledge and ability to provide quality care. This strategy also fosters an environment that allows higher education institutions and health care providers to collaborate (Keighley, 1999), although this is an ongoing, dynamic process which takes time to develop. This form of assessment can act as a catalyst for the creation of long-term partnerships.
One of the main challenges for clinical managers and educational institutions that implement this type of adaptation programme is to ensure parity for all foreign recruits across a range of specialties. It is also worth pointing out that if such an approach is to be successful it is crucial to ensure effective networking between mentors and nurse lecturers.
The programme has so far been offered to nurses working in elderly care, both in nursing homes and hospital trusts, medicine and critical care. Although there is no statutory need for this form of partnership approach in implementing an adaptation programme, we believe the structure we have outlined is a robust method of dealing with increased international recruitment of nurses by UK health providers. A lack of quality in adaptation programmes could have long-term consequences, affecting the fitness for practice of RGNs.