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A programme of supervised practice in a primary care trust

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In The NHS Plan (DoH, 2000), the government acknowledged the importance of nurses to the health service. The government also set itself a key objective to recruit male nurses into the NHS, of the right calibre, to enable it to meet the changing needs and expectations of people using the NHS and to continuously improve quality of care offered by the service.


VOL: 101, ISSUE: 22, PAGE NO: 32

Monday Iyore Ugiagbe, MEd, MSc, RN, ILTM, is coordinator for nurse recruitment, retention and return to practice at Tower Hamlets Primary Care Trust

In The NHS Plan (DoH, 2000), the government acknowledged the importance of nurses to the health service. The government also set itself a key objective to recruit male nurses into the NHS, of the right calibre, to enable it to meet the changing needs and expectations of people using the NHS and to continuously improve quality of care offered by the service.



In 2001 the Department of Health estimated that 35,000 additional nurses will be needed by 2008 and that several thousand of these will come from overseas (DoH, 2001). It is likely that the population served by the NHS will continue to be increasingly culturally diverse and complex.



It also seems likely that the NMC will continue to receive several thousand applications for registration every year from nurses who were trained outside the EU and want to practise in the UK.



International recruitment requires a huge financial outlay. Experience shows that it costs on an average of £2,000-£3,000 to recruit a single nurse from overseas.



In addition to the economic cost there are also social, political and human costs involved in international recruitment. For example, the nurses’ skills are lost to their country of origin, and they must adapt to a new country and health care system.



In order to ensure these nurses have the skills required by the NHS, and to orient them to the system, they are required to undergo a supervised practice (adaptation) programme (SPP) before they can register with the NMC. Fortunately, not all those needing to undertake SPPs are recruited from overseas (Ugiagbe, 2000). Many already live in the UK and are actively looking for a place in which they can undertake their programme.



Internationally trained nurses already living in the UK are a huge resource that should be considered in the drive to expand the nursing workforce. In addition to enabling avoiding some of the costs of overseas recruitment, they offer the NHS a range of benefits:



- As indicated in HR in the New NHS (DoH, 2002), a major government objective is the recruitment and retention of a workforce that reflects the diversity of the local community. These nurses help to meet that objective and thus enable the NHS to provide a culturally sensitive service.



- Unlike many of those recruited from overseas, internationally trained nurses already living in the UK are likely to be familiar with amenities within their community such as local markets, health centres, sport centres and places of worship. They will therefore not require as much support as those who are new to the UK.



- They are likely to be committed to working for their local trust because of their established links with the area.



- Many internationally trained nurses living in the UK will already have resident visas and will therefore remove the bottleneck caused by nurses having to wait for work permits.



- Trusts also have the advantage of being able to conduct the selection exercise themselves and are therefore more likely to find candidates that enable them to meet their objectives.



An SPP was set up in Tower Hamlets with a number of objectives. The aim was to:



- Provide clinical placements for internationally trained nurses resident in Tower Hamlets and East London areas;



- Enable them to qualify and practise as registered nurses in the UK;



- Increase the supply of nurses to the NHS locally;



- Enhance the ethnic mix of the local NHS workforce and therefore ensure it more closely reflects the local population;



- Enhance the quality and effectiveness of the local NHS services.



The primary role of Tower Hamlets Primary Care Trust is to provide health care to its local community, a culturally diverse inner-London borough. In the 2001 census it had 65,553 residents who were classed as Bangladeshi, 100,799 white, 6,596 black African and 5,225 black Caribbean (ONS, 2001). It was hoped that nurses admitted to the SPP would bring with them a rich and diverse knowledge of other cultures.



English is not the first language of most of the nurses in the SPP. It was expected that this would enable the PCT to provide rich and balanced quality care to its patients who speak languages other than English.



A proposal was put to the Tower Hamlets Council Neighbourhood Renewal Fund (NRF) to fund two clinical skills facilitator posts. Their role would be to provide teaching support, mentoring and assessment for SPP nurses within the trust.



Funding from the NRF was also used to support advertising, interviews and general administration for the initiative. The SPP nurses were paid a salary by the trust and were offered six-month contracts with guaranteed interviews for staff nurse posts on successful completion of the programme.



The North East London Workforce Development Confederation offered the trust £1,000 per nurse in order to supplement their salaries. The local university provided the programme’s theoretical input, using a work-based learning approach. The nurses were required to submit a reflective essay (2,000 words) towards the end of the placement. The university awarded 30 credit units at level two following successful completion of the programme.



In addition to the teaching sessions provided by the university, the clinical skills facilitators organised and coordinated in-house teaching and assessment sessions to ensure the nurses had the appropriate clinical skills.



Nurses recruited to the programme were split into two groups. The first started a week earlier than the second and spent the first week in general induction and preparation for clinical placement. That group was then placed in care of older people wards specialising in areas such as stroke, rehabilitation and continence care (Fig 1).



The second group also spent a week in class and was prepared for placement in the community. During their clinical experience in the community, they had placements with district nursing teams and opportunities to rotate to the health visiting or school nursing teams, depending on the availability of staff to support them.



The nurses also had a day set aside each week for study, when both groups attended same class and had periods for reflection on their practice. This cross-fertilisation of ideas and experience between the groups was extremely valuable in helping the nurses to understand the culture of care in the UK.



At the end of their first placement the groups came together for a one-week reflective session and preparation for their next placement. At this point of crossover, the nurses were becoming confident and highly motivated.



Clinical practice
The SPP nurses were employed by the trust for the duration of the programme. They worked 37.5 hours per week, including study days and as part of the team on the ward or in the community, and were required to work a minimum of two days a week in the practice area with their allocated mentors.



The nurses were also required to provide evidence of discussions and explanations given by mentors or other nurses and members of the multidisciplinary team and of relevant interactions with patients and relatives during direct contact or provision of care by logging them in their practice-based assessment competencies booklet.



The SPP nurses each presented a care study on a patient of their choice to a panel of two or three senior nurses.



This enabled them to demonstrate the kind and quality of care they had given to a particular patient, and the nursing research they had applied to that care. The care study was used as an objective measure that the nurse was able to provide high-quality, holistic patient care.



To ensure the nurses received effective guidance and objective assessment, the assessors used an agreed marking system. They scored independently and compared scores to agree an average mark for the nurse at the end of the presentation.



Senior colleagues who were not their regular mentors formally assessed the SPP nurses. This summative assessment confirmed the continuous assessment of the nurse undertaken by the ward and community staff or mentors in the administration of drugs to patients. Again, a marking system was also used in assessing the nurses to ensure objectivity.



The nurses were also encouraged to carry out a clinical teaching session, which they used to share ideas and knowledge from their care studies. This served to increase the nurses’ knowledge and other staff members’ knowledge of each SPP nurse’s strengths.



They were also required to keep a reflective diary on their experiences to encourage analytical and reflective practice and facilitate personal and professional development. The nurses used a standard format of reflection on action as well as in action.



The facilitators held both one-to-one and group sessions in which they could discuss issues with the nurses, while they also received regular feedback from their mentors, ward managers’ reports and the programme facilitators.



The community and ward managers involved in the programme completed standard monthly evaluation report forms on each SPP nurse. These reports covered issues such as the nurses’ level of attendance, punctuality, assertiveness, communication skills and relationships with patients, relatives and colleagues.



There were a number of challenges faced during the early stages of the programme. There was initial reluctance on the part of some managers to provide clinical placements due to the budgetary implications. In addition, some mentors who were already mentoring nursing students from the local university felt that the SPP nurses may bring additional pressure to the ward environment.



The local university has been commissioned to carry out an in-depth evaluation of the programme. However, all the nurses who completed it are currently working in NHS trusts - both acute and primary care.



In feedback received from a meeting with the nurses who had acted as mentors for the SPP nurses, one district nurse commented: ‘The team was very impressed by the depth of excellent practical nursing skills displayed by (nurse). We were so confident in her abilities that we allocated her a small caseload in her third week of placement.’



There are many benefits to providing a well-structured supervised practice programme for internationally trained nurses. For example, once they have completed the programme and become registered with the NMC they often want to work within the organisation where they under-took the programme.



Offering employment to these nurses helps to address the problem of high staff turnover while also increasing the diversity of the workforce, better enabling the service to meet the needs of the local community.



It also results in less expenditure by the trust on advertising, recruitment and selection and on staff training, and reduces insecurity and low morale among staff.



- This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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