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A review of a supervised practice programme for overseas nurses

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The evaluation explored the positive and negative experiences of internationally recruited nurses (IRNs) and their mentors during a supervised practice programme (formerly known as an adaptation programme) for IRNs at Leeds Teaching Hospitals NHS Trust. The aims of the exercise were to:


VOL: 100, ISSUE: 27, PAGE NO: 38

Marjorie Horner, BSc, RN, is supervised prac- tice facilitator, Department of Education, Training and Professional Development, Leeds Teaching Hospitals NHS Trust


The evaluation explored the positive and negative experiences of internationally recruited nurses (IRNs) and their mentors during a supervised practice programme (formerly known as an adaptation programme) for IRNs at Leeds Teaching Hospitals NHS Trust. The aims of the exercise were to:



- Assess the existing programme and the revised assessment documentation, which had recently been revised in the light of problems encountered by mentors;



- Improve the structure and delivery of the programme;



- Determine the factors that influenced whether NMC competencies for registered nurses could be met within the minimum three-month period.



Revitalising the NHS and implementing reforms to deliver modern health care services depends on having adequate staff in place (Department of Health, 2001). The government’s strategy for nursing, midwifery, and health visiting - Making A Difference (DoH, 1999) - and the human resources framework - Working Together, Learning Together (DoH, 2001) - promote action on recruitment and retention to ensure NHS aims are met.



The recruitment of IRNs and other health care professionals is seen as an integral part of the strategy for developing the workforce and modernising the health service (DoH, 2000).



The supervised of the previous course



For more than 15 years Leeds Teaching Hospital has been offering a supervised practice programme to IRNs wishing to gain professional registration to enable them to work in the UK. This was originally delivered on a relatively ad hoc basis and customised to meet the specific needs of individuals and the requirements of the organisation and profession. It was well established and successful in terms of maintaining the quality of patient care while ensuring patient-employee safety.



The programme operated under the auspices of the Department of Education, Training and Professional Development at Leeds Teaching Hospitals Trust, in partnership with key colleagues, whose specific responsibility was to oversee the recruitment and selection process.



Scale of the programme for the trust



In November 1999, the trust had 396 whole-time-equivalent nursing and midwifery vacancies (representing 9-10 per cent of nursing posts). About 70 per cent of these were for nurses and midwives, predominantly in specialist areas such as renal and liver services, intensive care, operating theatres, and care of elderly wards. It became increasingly clear that a more integrated, comprehensive and proactive strategy was necessary to meet the trust’s recruitment and retention needs.



Nationally and locally the trust’s advertising campaign, which had been sustained over several months, had failed to attract both the quality and number of nurses needed to fulfil service needs in most clinical areas. Other trusts in the UK had reported success in recruiting staff from the Philippines and Singapore so our recruitment efforts were targeted at these countries.



The arrival of the 291 nurses recruited from the Philippines and Singapore was scheduled in three separate cohorts to enable the practicalities of clinical supervision, coordination, and arrangement of suitable accommodation to be managed effectively.



Supervised practice programme
To register with the NMC IRNs are required to undergo a minimum period of three months of supervised practice with a named mentor or supervisor (UKCC, 1998). The Leeds Teaching Hospitals NHS Trust devised a standard, competency-based supervised practice programme to meet these needs.



The aim of the programme was to ensure the successful achievement of statutory outcomes and competencies for entry to the professional register, by enabling candidates to gain appropriate skills for safe, effective practice in their area of work (UKCC, 1998).



The course was intended to facilitate the IRNs’ integration into the UK nursing culture and to promote understanding of policies and procedures specific to the trust. The programme required the production of evidence to support the four main areas of competency:



- Personal and professional development;



- Professional and ethical practices;



- Care delivery;



- Care management.



Registered nurse competencies



The competencies that are required of a registered nurse are set out in The Nurses, Midwives and Health Visitors Rules Approval Order 1983 (UKCC, 1998), which states: ‘The experience shall provide opportunities to enable the individual to accept responsibility for his/her personal professional development and acquire the competencies required.’ These competencies include:



- Carrying out the activities involved in conducting a comprehensive assessment of nursing requirements;



- Recognising situations that may be detrimental to the health and well-being of the individual;



- Advising on the promotion of health and the prevention of illness;



- Devising a plan of nursing care based on the assessment in cooperation with the patient;



- Recognising the significance of the observations made and using these to develop an initial assessment;



- Implementing the planned programme of nursing care and, where appropriate, teaching and coordinating the work of other members of the care team who may be responsible for implementing specific aspects of care;



- Reviewing the effectiveness of nursing care provided and, where appropriate, initiating any necessary action;



- Working in the multidisciplinary team;



- Managing the care of groups of patients over a period and organising appropriate support services.



Mentors and supervisors are responsible for providing supervision and assessment and for confirming that the practitioner has met the registration requirements. This pivotal role is further supported by the availability of a programme to prepare supervisors and mentors wishing to take part in the IRN programme.



The supervised practice facilitator
The role of the supervised practice facilitator at Leeds was developed as a result of the growing number of nurses applying to the supervised practice programme and, more specifically, the need to coordinate closely the programme for the 291 international recruits from Singapore and the Philippines.



The role and responsibilities of the supervised practice facilitator are to:



- Oversee the administrative function needed to coordinate successful placement for the IRNs;



- Provide preparation and support to the supervisors/mentors and the IRNs;



- Ensure that NMC requirements for IRNs are met through registration and record-keeping;



- Provide necessary programmes and monitor the progress of the IRNs using either one-to-one supervision or group supervision;



- Advise the trust on all issues related to registration with the NMC.



The mean time taken by the IRNs to complete the supervised practice programme between July 2000 and May 2001 was 5.18 months. Between August 2002 and January 2003 the mean time decreased to 3.42 months. This would seem to indicate that the role of supervised practice facilitator has directly influenced the time it takes nurses to complete the supervised practice programme, reducing this by 2.76 months (Fig 1).



Evaluation of the experience of IRNs



A series of individual semistructured interviews was undertaken with the IRNs. The common themes that emerged were used as the basis for structuring the questionnaires. These were sent to the known 460 IRNs in the trust to elicit their view of the supervised practice programme. The response rate was 23 per cent (106), which was low, so the results must be viewed in context.






In answer to the question: ‘How beneficial was the supervised practice programme?’:



- 102 IRNs thought it was ‘very or quite beneficial’;



- Four believed it to be ‘not very beneficial’;



- 11 nurses said the programme had ‘helped them to learn about the NHS’;



- Eight felt it had ‘helped them gain confidence’;



- Two said it had ‘helped them settle into the ward’.



Responses to the question: ‘How long did it take you to complete the competencies in the programme?’ included: ‘Cardiology was new to me but with the help of my mentor I finished the adaptation programme within three months.’ (The cardiology ward led the way in shortening the time it took IRNs to complete the programme.) One nurse felt that the attitude of the mentor could directly influence the time it took a nurse to complete the programme.



All 106 respondents agreed that having a mentor was ‘very’ or ‘quite important’ but 11 said that their mentors had not been very helpful and had failed to recognise the IRNs’ existing knowledge.



Replies to the question about whether the IRNs had encountered any difficulties during the programme (Fig 2, p39) brought a range of responses:



- Insufficient time working with their mentors;



- Feeling the mentor had little knowledge of their skills;



- Communication difficulties because of a mentor/supervisor’s regional accent;



- Feelings of being ignored;



- Feeling untrusted and discriminated against on racial grounds.



Respondents were also asked what other subjects could have been included to improve the programme. Eighty-seven nurses put forward suggestions to improve the programme, while just 19 respondents made no suggestions. The suggested topics included:



- Intravenous administration;



- Details of ward routines;



- English terminology;



- Cultural diversity;



- Using a reflective journal.



Finally, the nurses were asked how useful they had found the update sessions. Fifty-seven had attended the sessions and had found them useful, while 18 had not attended or had had no knowledge of the sessions.



However, there was positive feedback in terms of the usefulness of the update study days. Nurses commented that the sessions had helped them to expand their knowledge and boosted their confidence, and that they had received essential information as to what to expect in the clinical area. They also said that the sessions had offered them an opportunity to engage in support networking.



Mentorship and supervised practice
Part of the programme focuses on mentorship preparation and support, and it was identified that evaluating the experience of the mentor was essential. The results will be used to help support them.



Anonymous questionnaires were sent to 100 known mentors, 25 per cent of whom responded.



Respondents were asked whether they had attended the mentors’ preparation programme - 14 answered ‘yes’ and 11 ‘no’. Of those responding ‘yes’, six found the programme to be very beneficial, another six found it to be quite beneficial, and two did not find it very beneficial.



Respondents felt an explanation of the assessment document and competency booklet should be included in the mentors’ programme, as well as more information on British culture to help the IRNs to integrate.



The evaluation also focused on how user friendly they found the competency booklet. Responses included:



- Six respondents found it very user friendly;



- 18 felt it was quite user friendly;



- One did not find it user friendly at all;



- One mentor commented that the revised assessment document was better set out and easier to use.



The respondents were asked who supported them while they acted as mentor to an IRN. The results revealed that most mentors had had support, with 16 supported by their ward manager, 16 by their peers, eight by a supervised practice facilitator, five by a senior manager, and three by a senior nurse. Four mentors said they had had no support. One mentor commented that she knew where to access more support in case of any problems. Respondents were asked about the positive (Fig 3) and negative (Fig 4) experiences of mentoring.



Finally, respondents were asked what additional help they would find useful while mentoring IRNs. Seventeen said that one-to-one support in the clinical area would be helpful, nine were in favour of focus groups to share positive and negative experiences, and eight said they would value a surgery or open-door session.



One mentor had enjoyed the role and stated that she would do it again, given the opportunity. Others felt that more facilities should be provided for IRNs to help them improve their communication skills for safe practice. Further suggestions included more study days for mentors in the first three months of the supervised practice programme and a buddy system for new IRNs.



The results of the survey were used to inform a series of recommendations. It was felt that the trust would benefit from better recruitment and selection processes, such as including an assessment of applicants’ English language skills. Communication is the basis of all nursing activity and to protect patient safety, the IRNs are now required to undertake an English language proficiency test if English is not their first language (UKCC, 2002).



Better preparation before IRNs begin their supervised practice placement was also recommended. This will promote understanding of all the aspects of adapting to work in a new environment and help IRNs to integrate professionally, clinically, culturally, and socially. This preparation would probably take the form of a short preadaptation programme.



Another recommendation was to set up a mentors’ focus group to enable them to discuss and share issues and experiences during the programme. This could be an essential part of a revised mentors’ programme, as could holding one study day a week during the supervised practice programme. This has now been made part of the revised supervised practice programme.



Finally, incorporating within the trust’s strategy policies to address the perceived or real experiences of racism through, for example, cultural diversity learning packages, was considered an important issue. Developing a support network initiative for IRNs, mentors, and other staff to promote retention was also felt to be an important consideration.



The findings presented in this article show that both IRNs and their mentors had positive and negative experiences during the supervised practice programme.



Both groups highlighted similar issues with regard to the competencies required by the NMC, for example communication and language problems, staff and patient attitudes toward IRNs, and lack of support and guidance.



The study is limited by its small sample size, and a further study is warranted.



The IRNs felt that having good support, guidance, and understanding would help them to achieve the competencies within three months. Similar comments from the mentors suggest that they also felt in need of more support and guidance during the programme.



The IRNs felt that insufficient time had been allocated to working with their individual mentors, as a consequence of which mentors had little knowledge of the IRNs’ existing skills. Time was also an issue for mentors, who felt the experience had been hard work and very stressful. Some IRNs also felt that they had been ignored, not trusted, or even racially discriminated against.



An assessment of some of the core skills of IRNs before they embarked on the programme would have been beneficial, as would a review of their competencies (such as performing venepuncture and cannulation) before they started supervised practice placements.



The study showed that it is possible to complete the supervised practice programme and meet the competencies required by the NMC within the minimum three months. The trust’s cardiology team set a precedent - through optimal mentorship it enabled IRNs to complete the programme within the minimum time.



Overall IRNs enjoyed the programme, learnt from it and fulfilled the learning outcomes. The mentors felt that they developed a good relationship with the IRNs and had the chance to understand a different culture. They also felt that helping someone to settle into a new environment and mentoring a motivated student was a very satisfying experience.



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

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