Rapid Essay Researchers We offer fast essays with the best content
Table of Contents
Abstract 3
CHAPTER 1: INTRODUCTION 4
Background 4
Skills Required by Nurses 4
Teaching Interventions 7
Research Questions 8
Problem Statement 8
Significance of the Action Plan 9
CHAPTER 2: LITERATURE REVIEW 11
Implications for International Nursing Students 11
Understanding the Healthcare System of Finland 11
Common Challenges Faced by International Nursing Students 13
Cross Cultural Communication with Patients 16
Patient Care Nursing Intervention Strategies 19
Employing Critical Thinking 21
Lessons for Nursing Tutors 24
Different Learning Styles in Technical Education 24
Kolb’s Learning Styles Model 24
Dunns´ Learning Model 25
Teaching Approach to International Nursing Students 26
CHAPTER 3: ACTION PLAN 29
Simulation Activities 29
Empirical Evidence 29
Role Play 29
Computerized Patient Simulator- SimManTM 31
EBP for Using Patient Handling Tools 32
Empirical Evidence 32
Prohibiting Drag Lift Technique 33
Use of Automatic Ceiling Lift versus Transfer Board 34
CHAPTER 4: ANALYSIS OF ACTION PLAN 36
CHAPTER 5: CONCLUSION 38
REFERENCES 40
Abstract
International nursing students in Finland face personal and social challenges during their studies and clinical practices as they are not accustomed to the teaching styles and social cultures of the society. For successful transition from the initial learning phase to the practical implementation stage, the nursing students need to follow structural procedures and cross-cultural communication strategies in order to equip themselves with a better understanding of the norms and public nature in the country. Furthermore, the profession of nursing demands critical thinking and adaptability of nurses, as standard approaches are often not applicable to a specific case. Engaging in critical questioning and reasoning practices would help the international nurses to make a sound and justifiable link between patient needs and the employed care intervention. The role of senior nurses and tutors is very important in this respect as they can sail the nursing students, particularly the ones from diverse background, by sharing their experiences and enabling them to critically analyze between multiple treatment alternatives. Simulation activities of “role play” and SimManTM application has also been covered in the report. It has been found that when nursing students are placed into clinical setting, they often lack the confidence and practical experience to take wise decisions. For this reason, integrating simulation activities with the theoretical lectures can help in bridging the gap between theoretical knowledge and practical implementation of it. From the literature it has been found that nurses are often reluctant to communicate and make bonds with patients, who are from a different linguistic or cultural background. Efforts has been made to introduce strategies through which nurses can make better social and personal bonds with their diverse culture patients, using human or interpreters online translation software tools for communication.
CHAPTER 1: INTRODUCTION
Background
Nursing is a widely growing field and its global expansion is giving roots to the expansion of diversity and cross-cultural setting in the field of nursing education. Irrespective of the diversification of the student pool in the nursing education, it is one of the fields that have been in debates of theoretical versus practical education for a long time (Oermann, Harris, & Dammeyer, 2001). The critical job nature and responsibilities of the registered clinical nurses makes it imperative for the tutors and educators to ensure that the nursing graduates are not only equipped with the theoretical knowledge base, but also have a keen understanding of its practical implementation when giving acute patient care. Riley & Fearing (2009) state that when dealing with technical courses like engineering, nursing, or teaching, there is always a concern of the learning styles of the students and the teaching styles of the tutors. It has been found in a number of researches (Popoola & Hendricks, 2014; Hallin & Bostrom, 2014) that the meta-cognitive development of student’s knowledge and their ability to implement the learned knowledge practically differs with their learning style and whether it matches or not with the teaching style employed by the tutor. The challenge of catering different student’s needs augments in a cross-cultural setting, when the teacher has to take into account the barriers of language, culture, and environment. For this reason, it is suggested that tutors use a variety of teaching styles and activities in order to develop the cognitive learning of the international students, ensuring their ability to implement the learned knowledge.
Skills Required by Nurses
Nursing can be deemed as one of the diverse fields, where the practitioners require a number of skills and attributes to fully justify with their profession. These skills include communication skills, compassion skills, children handling ability, elderly support, and various other skills that are associated with this profession. The international nursing students in Finland should bear in mind that they would be put in different medical care situations and they have to prove their credibility in all situations in order to justify their competency in nursing. According to the study of Kokko (2009), a number of medical units worldwide abide by the traditional approach, where a nurse is put into one designated unit and s/he serves only in that unit. However, due to the lack of availability of nurses and a more unorthodox culture followed in Finland, nurses serving in the childcare unit will be expected to have the same level of competency in handling adults and the elderly people, and the nurses will be called on to serve in other units at some point in their clinical career. Thus, it is imperative for the international students to understand this unconventional culture in Finland, and polish their nursing skills so to serve a diverse patient pool.
One of the case studies extracted from Luxury Care Aranlaw House in Poole presents a woman, 78 years of age, with the problem of vascular dementia, who is brought to the medical facility (Luxury Care, 2012). She is unable to remember things and often forget her own home address. Furthermore, her memory problem also results in skipping her medicines or having wrong medication or food, which can put her health at stake. When she was brought into the medical facility by her family members, she was not happy and was upset about the fact that she could live in her own home, where she spent a great part of her life. The report presents that even though if the doctors and nurses have provided acute care and complete medical support to the woman, she would be satisfied as she do not wanted to stay in the hospital. For this reason, the nurses started mingling-up with the patient, without discussing anything about the problem. The dedicated nurses first collected necessary information about her from her family and neighbors, who have known her for a long time. As discussed by Conner, Copeland, Grote, and Koeske (2010) that elders at this stage of their life become cautious about their surrounding and often do not appreciate their dependence on others. Owing to this mental attitude of the elderly people, the nurses and carers in the facility do not force the patient to take medicines in the first week and allowed her to go to her allotted room at any time without any interference. This enabled the patient to develop a relation of friendliness and trust with the caregivers, and she started recovering very nicely.
Though managing the elderly group is quite challenging, but the job of emergency room nurses, particularly the ones with child cases, not only have to deal with the medical procedures, but also have to communicate with their families and keep their nerves calm. Laura, a pediatric staff nurse, works in a children’s hospital as a Band 6 staff nurse in the recovery area. As recovery nurse, her core responsibility is to ensure the stable health condition of the patients, providing them airway until they are able to breathe comfortably by themselves (Prospects, 2012). Laura also has to make routine visits to check on her patients and record their pulse rate and blood pressure. One of the challenges she face as a recovery nurse is during accidental cases, when she is required immediate measures for ensuring that the child does not lose his/her breathe. The child parents on the other hand, also sometimes give a hard time to Laura and other nurses in her department, as they are always concern with the health of their child and have a negative perception that the hospital staff is lazy and delay procedures willingly. She has developed managerial and leadership skills in order to inform the parents about the current status of operation, and try soothing their nerves by talking about other similar cases or asking parents the tales of their child. Thus, nurses not only need to be medical facilitators, they also have to be emotional and moral facilitators. Owing to this presented scenario, the international nurses are required to develop their leadership and communication skills in order to provide comfort and care to patients and their relatives (Conner et al., 2010).
Teaching Interventions
Teaching a pool of nursing students from diverse backgrounds can be intricate at times, because of the barriers of language and different cultural orientation. One of the aims of this study is to shed light on the role of nursing tutors dealing with a pool of international students. Bednarz, Schim, and Doorenbos (2010) state that using the traditional teaching approach, the tutors will only walk in one direction, where they will explain the medical state and general regulations to abide by and standard medical procedures that needs to be followed under specific circumstances. However, the unconventional approach for teaching international students is to understand their cultural attributes so to better assist them in their learning process and identifying heir distinct strengths and weaknesses in patient handling and team work. Bednarz, Schim, & Doorenbos (2010) discusses a case study in which a Chinese students was given the task of giving medicines to a patient and keeping the record of it, in the first year of the nursing program. What the teacher did not realize is the change in language and intonation that would affect this task. The tone of Chinese people is harder than that of the Westerners. When the Chinese student asked the patient to take the medicines, she just said the word “Take”, which sounded harsh to the patient, while it was the usual way of saying for the Chinese student. Such situations are common in a multi-cultural setting, which can be reduced if the tutor is aware of the cultural differences and distinct behaviors and learning styles of the students (Bednarz, Schim, & Doorenbos, 2010).
Riley and Fearing (2009) advocate the peer-teaching technique for developing self-management and critical thinking skills in the nursing students. Riley and Fear explain that when students are made to work with each other or assess each other’s work, they are playing the dual role of a practitioner and also an examiner. This develops their critical leaning skills as they try to assess other nurses from the perspective of the patient or the hospital management and other settings. Student Mentor program is another common teaching style, similar to that of the peer-teaching. In the Student Mentor setting, students in the third year or final year of MSN or BSN program are asked to instruct and facilitate the fresh nursing students. This setting has been favored in the cross-cultural setting, as students from different cultures get a direct exposure to other cultures, which helps them in strengthening their cross-cultural communication between the patients and the fellow nurses.
Research Questions
1. How can monitoring nurses enhance the level of confidence of international nurses to handle patients in tense situations?
2. How can nursing tutors improve the technology awareness and patient handling skills of the international students?
Problem Statement
The Finland’s healthcare system is more culturally diverse than the general population of the country, and many regard Finland to be a homogenous society. For this reason, it is often intricate for international nursing students to interact with the local residents and provide them with adequate care. The need of nurses in Finland has opened opportunities for a large number of foreign students to pursue their degree from Finland and then practice nursing in the country; however, the cultural transaction in Finland is quite different than several other European countries (Kokko, 2009). The cultural and language gap between the tutors and the students is another obstacle that decreases the level of effective communication and social bonding between the students and the teachers, which is essential for knowledge sharing and problem resolving. Cioffi (2003) has discussed anxiety problems in nursing students due to the predicament of language understanding and getting command over the medical technology in use. Students coming from countries with less sophisticated medical system are often unaware of latest technologies used and lack skills of handling them (Mariani, 2009). These are some of the issues that get shadowed by both students and tutors, thus, prolonging the unease and anxiety level of the international nursing students. Realizing the common challenges and their mitigation strategies would allow the tutors to better assist the students, belonging from different cultural and social background.
Significance of the Action Plan
The patient to local nurse or caregiver ratio in Finland is not adequate to provide immediate attention and acute care to all patients, particularly during peak hours. For this reason, Finland has open opportunity for medical students of different countries to study and practice nursing in the country. However, the distinct culture of the country possesses several barriers and challenges for the foreign students, let alone the fundamental challenge of language difference. A number of cases has been recorded where international nursing students and fresh graduated nurses were asked to stop their medical practice in Finland, as they were unable to provide acute care to the patients, as a consequence of their inability to communicate effectively in the local language and comprehend the nature and demands of Finland’s healthcare system (Rautakoura, 2012). For this reason, this report aims to serve as a guide book for new and old international nursing students, studying in Finland and ambitioning to pursue a career in nursing in the country. The report will provide a comprehensive overview of the common challenges faced by the international students during lectures and clinical practice and interventions to lessen the impact of these challenges on the performance and competence of the students.
Moreover, this report also aims to serve as a guide for nursing tutors, who are supervising or instructing nursing students from diversified backgrounds. Nursing tutors can refer to this report for learning the different learning styles of students and what strategies they can opt in order to facilitate the learning style of more students in their supervision. The Action Plan provided in the report can be used by tutors in their lectures and clinical assignments or by the nursing students in the supervision of senior nurses, in order to refine their critical thinking and patient handling skills. The Action Plan designed for this report is focused on Evidence-Based Practice for patient handling and Simulation activities for enhancing critical learning and patient treatment skills. Both patient handling and critical thinking are some of the basic requirements in nursing, thus, this report can be taken as a guide by both local and international nurses. The activities and learning experiences has been designed from the tutors’ perspective, meaning that a supervisor or senior nurse would be required for conducting these activities in the correct manner.
CHAPTER 2: LITERATURE REVIEW
Implications for International Nursing Students
Understanding the Healthcare System of Finland
The healthcare system of Finland is regarded as one of the finest in the world, and the majority of the patients are treated in public-care facilities. In the year 1982 Finland made an agreement with WHO to act as a pioneer country in the healthcare provision and design approached and for improving the global healthcare status (Schulenburg & Blanke, 2004). For this reason, heavy responsibility is put on the shoulders of medical practitioners, including the registered nurses and the nursing students, as the medical facilities expect them to fulfill the prime mandate of the local healthcare facilities. Thus, the international nurses need to closely observe Finland’s healthcare operations so to fully understand their roles and responsibilities in the placed healthcare unit. Moreover, most of the medical expenses are paid through public funds, collected through taxes and other public and private means. However, in some cases, the patients have to bear part of the medical expenses, which can be of their medicines, dental treatment or other treatment procedures. Thus, it is important to prior inform the patients about the status of their treatment, and whether or not they would be liable for some of the medical expenses (Jakubowski & Busse, 1998). One of the problems that occur in this setting is that nurses are often unaware of the supplementary cost doable to the patient and tell them informally that they would not have to pay any cost, when asked. This can create conflicts between the hospital administration and the patients. For this reason, it is essential for both the student nurses and the registered nurses to study each case and discuss with the hospital management, before providing any medical expenses or other details to the patients.
According to the report of Jakubowski and Busse (1998), there are nearly 3,000 public health centers located in Finland, which are operated by the health care municipalities of the country, while the others are operated by private owners and investors. Though, the quality of healthcare is almost the same in both public and private healthcare, the time required for getting an appointment and waiting time within the health facility could differ to a great extent. Kokko (2009) in his study found that the number of physicians in Finland’s public care units is insufficient to handle the patient inflow during peak hours. A number of patients are unaware of other private medical facilities, where they can get their treatment done, but would have to pay the entire cost or at least half of the cost of their medical treatment. If nurses are working in the public care units, they should have knowledge of other public and private healthcare units, which provides acute care for the same disorder. This would help them in properly guiding patients, who require immediate attention to be transferred to other public or private care centers, in case of unavailability of the concerned physician (Kokko, 2009).
It should also be noted that medical laws and standards are quite high in Finland as compared to several other developed and underdeveloped countries in the world. Medical malpractice is a very serious crime in Finland and can put to stake the reputation of the institution and the medical career of the practitioner. According to Finland’s Patient Insurance Act, the medical facility would be liable to bear complete expenses of medical treatments and medicines that result out of a malpractice (Hirvensalo, 2006). All patient claims are handled by the Ministry of Health, which decides the penalties and other legal procedures for the health practitioner and the healthcare unit. It implies that any negligence in the clinical setting can lead to a catastrophic situation for both the practitioners and the institution. Owing to this healthcare system, it is a matter of high concern that all medical procedures and decisions are taken in accordance with the Finland’s Health Advisory Council, and physicians are involved in any decision related to patient care and handling.
Common Challenges Faced by International Nursing Students
According to the study conducted by Jones (2010), the challenges faced by international nursing students during their education and clinical work depend on their linguistic, cultural, and pedagogical background. Surveying a number of nursing students engaged in their research work, Jones found that the primary problem which many international students faced was of the student-centered learning process. Compared to the teaching approach in a number of Asian and American countries, the European countries employ a more stringent teaching approach, where students often have to deal with their study-related problems by themselves. Students coming from other countries found it difficult to manage their studies as they felt the lack of guidance and supervision provided to them. However, as the local students were familiar with such a teaching culture, they had adapted themselves to it, and thus, this problem was not a big concern in the local nursing students.
Another problem identified by Evans and Stevenson (2011) is that nursing students are given practical and research tasks, which they have to complete in groups. A common observation is that international students tend to make bounding with other international students, particularly with the ones from the same linguistic background. Owing to this observation, when nurses are given tasks of patient observation and clinical trials, the group of international nursing students faces more difficulties than the local students, as they are unaware or uncertain of patients’ distinct cultural and emotional needs, which limits their capability of providing acute care. For this reason, it is essential for the international nursing students to peer-up with the local students in order to better understand the untold needs of patients, when they are brought into the primary care units. As a nurse is expected to provide both medical and emotional care to the patients, it is imperative for all nurses to understand the general physic of the local patients, general family issues, and other problems pertaining in the society (Evans & Stevenson, 2011).
The healthcare system of Finland is in many ways more mature than several other Western and Asian countries. For this reason, the use of latest technology in primary healthcare has become a norm, and the health practitioners are expected to have a sound understanding of the latest medical equipment and devices (Malecha, Malecha, Tart, & Junious, 2012). For the ones born and brought-up in Finland, it is a norm to see or operate such devices as they have been into operations for a long time, and the local nursing students are aware of the fact that they will have to work on simulation software applications and other technological devices during their BSN and RN programs. However, the medical technology of Finland often looks new and peculiar to students from other countries, and they have hitches in adapting to it. The major problem is that often the nursing teachers ignore the fact that some of the technological devices and equipment are not common for the international students and they should be given extra time and attention in order to improve their familiarity with the devices and computerized operations. A number of international nursing students surveyed in a US medical institute said that they are unable to fully comprehend the mechanism of the new devices and this affects their grades. Some of the nurses remark that they have to record observations and patient progress in a computerized program (patient database), which is quite intricate than the manual recording of observations. This explains that if the nurses are having difficult time managing the installed technology, they will deem unprofessional to the patients or their family members, and their ability to provide acute care will also be limited (Malecha et al., 2012).
Another predicament observed among the international nursing students and the international nurses is that their lack of knowledge of the patient referral system (Oermann, Harris, & Dammeyer, 2001). As they have come from a different environmental setting, they have little knowledge of the administrative setting in clinics, and therefore, when placed in clinics or medical facilities, have hard time getting accustomed to it. The problem identified is that nurses do know where to refer a patient, but have inadequate knowledge of the proper protocol about when and in what conditions to refer. Malecha et al. state that nurses in the primary care unit are expected to not only treat the problem, but also diagnose the cause of the problem. A number of international nurses were found to lack in their skills of etiology diagnosis, where physiologic, psychological, sociologic, spiritual, or environmental causes of the disorder are analyzed. This requires additional efforts from the international nurses to understand the basic society norms, in order to get a better understanding of the prevailing social and emotional problems in the local societies. This would also enable these nurses to get a better understanding of the hospital cultures, as they also reflect the basic societal norms and culture.
For international students to be mentally prepared for the predicaments and problems they might face during their nursing studies, it is important to get some idea about the sources of stressors for the international students. Knowing these stressors, the new and old students would be mentally prepared to face them and would also be able to plan mitigation strategies for them, rather than being shattered and caught in anxiety. One of the personal sources of stressors noted in the international pool of nurses is of the dual responsibilities on their shoulders; studying and earning (Singh, Sharma, & Sharma, 2011). A number of international students have to earn their living in order to meet their daily expenses of food and accommodation, and this adds further burden on their shoulders when they are already captivated by their college projects and assignments. Thus, students coming to study in Finland should facilitate their earning means and plan the hours they will work to make sure they are not stressed out, and are able to perform well in their studies. An option for a number of international nursing students is to work part-time in the institute they are studying, serving in international student affair or other departments. Singh et al. shed light on the stressor due to social factors of peer competition and high expectations from the supervisors. As international students are trying to adapt to the new environment, language, and culture, they are also confronted with the on-going competition in their classes, when they are also expected to learn and understand with the same pace as that of the local nursing students, which sometimes becomes too much for the international students to deliver. The coping strategy for such social stressors is to know the personal strong and weak areas, and discuss it with other peers and teachers in order to get better assistance and support. Klauer and Filipp (1993) refer five coping strategies of seeking social integration, rumination, threat minimization, turning to religion, and seeking information for minimizing the social stressors in a new place.
Cross Cultural Communication with Patients
Finland is not a very culturally diversified country, and the majority of the residents are Finns, with primary languages of Finnish and Swedish. English is spoken by a small majority of population, and this is why it is imperative for the international nurses to get command over the primary languages or at least the national language of Finnish, in order to communicate properly with the patients. Rautakoura (2012) states that when there is a lack in communication between the nurses and the patients, the chances of medical risks or not providing adequate care to the patient increases, which can put the safety of the patient on stake. Moreover, it should be noted that as employment opportunities are growing at a rapid pace in the country, particularly in the fields of medical and technology, the country will grow more and more diverse culturally over the next few years. Thus, the international nurses need not only to study and understand the local culture and language, but also the distinct cultural values and beliefs of all of their patients in care. It has been found in the study by Cioffi (2003) that nurses are often reluctant to ask general health related questions, from patients who belong from other cultures and speak different languages. The common attitude found in nurses is that when nurses are not able to properly convey the message to patients, it will lead to further anxiety in patients and for this reason it is better to reduce interaction with patients of different languages.
Gerrish, Chau, Sobowale, and Elizabeth (2004) shed light on the practice of giving due respect and concern to each patient, irrespective of their language. A number of patients rely on the primary care nurses for their moral and emotional support, and thus, it is essential for nurses in those units to be available for the patients for all their needs. One solution for better handling communication barriers is of employing phone interpreters for patients calling to the hospital. However, this intervention is not very feasible when face-to-face conversation is involved. For the majority of the cases, a good command over Finnish would be sufficient to interact with patients ad understand what they are asking for. However, for hospitals with mire culturally diverse pool of patients, the international nurses would be required to go one step further in order to provide necessary healthcare and other support. The nurses should have an idea of the different cultures and types of people living in the country in different locations, so that as soon as a patient is admitted, they have a rough idea of the cultural background and spoken language of the patient (Cioffi, 2003). Nurses can employ Google translating application or other translating mechanism available in order to translate general patient questions and patient survey form in different languages. Firstly, languages of Finnish or English should be used as the mode of communication with the patient; however, if discovered that patient is not comfortable with wither of these languages, then efforts should be made in identifying patient’s primary language, and then using human language interpreters, voice interpreting software tools, or other applications in order to translate basic questions to be asked from Finnish or English to the desired language.
Walker, Hall, and Hurst (1990) claim that diagnosis of different health disorders should take into account the different socio-religious beliefs of the patient. A common practice found in a number of healthcare organizations is that a culture of “doctor know everything” is employed, and less concern is given to patients’ views about their problems. In various cultures, health problems and sickness is related to religious beliefs of sins and divine punishment or take roots from social structures and mindsets that if a problem subsist in a society or family, it will probably infect all or majority of the members of the society or family. Owing to these observations, if the diagnosis done is based on medical symptoms alone, then the medical practitioners will not be able to identify the mental attitude and psychological factors that lead to this problem. For this reason, it is essential for nursing practitioners to communicate with patients about their family history, their religious beliefs, and what they think is the root cause of their health problem. In their book “Clinical Methods: The History, Physical, and Laboratory Examinations”, Walker, Hall, and Hurst mention a case study of a 25 year old graduate student, having the health problem of sluggishness due to food allergy. Based on the description of the patient, the following conceptual model was created by the researchers (Walker et al., 1990).
Figure 1: A Patient’s Explanatory Model for his Illness- Before and After Physician’s Input
(Putsch & Joyce, 1990)
The patient was losing continuous weight due to the belief that food id causing him problems, and this further pushed the patient towards weakness and sluggishness. The health practitioners understood the situations and changed the belief model of the patient, rather than simply providing supplementary medicines. The basic belief of food allergy was eradicated and the patient was able to look at healthier eating options to regain his health status. This entire process would require nurses to be actively engaged with their patients so to better understand the general psychology and mental barriers that are causing the disorder to persist (Putsch & Joyce, 1990).
Patient Care Nursing Intervention Strategies
Some of the common problems that nurses encounter on regular basis is of manual handling of the patients. In a number of studies and surveys taken on the experiences of clinical nurses, it was found that when patients, who are unable to move, are transferred more one bed to the other or to the wheel chair, there is a certain risk of musculoskeletal disorders, if not handled properly. According to the study by Fragala & Bailey (2003), there has been a steady decline in back injuries and other musculoskeletal disorders due to occupational accidents over the last decade; however, these cases tend to increase in the nursing profession. Nurses are required to transfer patient during dressing, toileting, bed shift, and several other scenarios, and often a patient has to be moved more than three times in a day. This increases the probability of mishandling the patient, particularly during peak hours of the hospital. A nurse from the US medical center stated that the risk factor increases when one nurse is asked to carry out all tasks, and she has to take care of a large number of patients at a single time. Thus, the core problem is not improper handling by the nurse, but the lack of availability of sufficient nurses in the hospital facility. What nurses need to do is to inform to their supervisors or administrative department about the time required to carry out the given tasks and the time given to them. If this is not communicated properly, there are like chances of mishandling events. In addition to this, some of the nurse recommends the use of back-belts, ceiling lift, and patient stand transporters in proper patient handling. In case of high risk activities, it is imperative for nurses to employ the relevant equipment available in order to lessen the chances of bone and other injuries (Nelson & Baptiste, 2004).
Kathleen Stevens (2013), a Doctorate in Nursing, discusses the impact of Evidence-Based Practice (EBP) in Nursing. For providing acute patient care, it is very important for the nursing students to verify their nursing strategies and their short-term and long-term impact on the health and overall life status of the patients. For applying EBP, nursing students are required to not just learn theories, but also verify their practical implementations to comprehend their advantages and disadvantages. For instance, one common practice in the field of medical care is that patients are asked to carry out their medical tests, when they enter into the primary care unit or submit their form foe entrance. This has become a standard approach and almost all patients, regardless of their medical history and their last test date, have to again carry out different medical tests, and only after submitting those tests their medical procedure is initiated. Stevens (2013) states that in a number of situations, the previous health records and medical test history of patients are sufficient to progress with their healthcare procedures, and the standardization of medical tests and report submission policy leads to redundancy of tests, delay in actual treatment procedures, and eventually dissatisfaction of the patients. Owing to this fact, the nursing entering into the healthcare system, need to realize standards and policies, which cannot be applied at all situations. An ACE Star Model has been presented by Stevens for improving nursing practices based on the EBP framework (figure 2).
Figure 2: ACE Star Model of Knowledge Transformation (Stevens, 2013)
Evidence Summary would require the nurses to peek into the medical database of patients and learn their treatment approach and their satisfaction level. The third point of Translation into Guidelines explains that nurses should realize that whether the chosen approach or steps were a mandatory requirement by the National Health Association or it was the standard of the particular healthcare. In this way, the nurses would be able to differentiate between government imposed medical procedures and administrative imposed health procedures and regulations. Through simulation activities and imitating actual patent-care scenarios, the international nurses would be able to evaluate the practical integration of those practices and observe their outcomes in terms of acute and satisfactory care provided to the patients (Stevens, 2013).
Employing Critical Thinking
Critical thinking is one of the essential parameters in nursing education, and nurses are supposed to drive patient care interventions from their critical thinking approach rather than employing the standard regulations and procedures for all cases. According to the definition provided by Yahiro and Saylor (1994) “the critical thinking process is reflective and reasonable thinking about nursing problems without a single solution and is focused on deciding what to believe and do”. Yildirim and Ozkahraman (2011) state that international nurses are often captivated by the legal policies and standard approaches to clinical care, and this is the reason that though there are separate modules and lectures on critical thinking in nursing education, it is not implemented properly in clinics and health facilities. The international nursing students have a good opportunity to use their critical thinking skills as they knowledge of different cultures from their home countries and can apply this diverse culture knowledge to evaluate policies and procedures. A number of medical theorists and practitioners define critical thinking to be open-minded questioning process, where the nursing practitioner can ask questions from themselves or from their supervisors about the significance and validity of the patient care approaches employed in the health facility. Extracted from the study by Yildirim and Ozkahraman, graduating students should make it a habit of asking or reflecting on the following questions to enhance their critical thinking skill.
i. What is the issue?
ii. What information do I need and how do I get it?
iii. Are my data valid and applicable to the particular patient?
iv. What do the data mean, based on the facts?
v. What should I do?
vi. Are there other questions I should ask?
vii. Is this the best way to deal with the issue?
viii. What problems will be incurred from the current approach?
ix. What alternatives are available and why they are not chosen?
The role of nursing tutors is pivotal in developing the critical learning skills of the nursing students, as they alone would not be able to get sufficient information on healthcare policies and procedures followed in individual healthcare units, which varies as per the needs of the patients. The first step in the critical thinking process is the ability to question on the present procedural and other operations carried in hospitals. As a number of international students would have problem in direct communicating or in sharing their views in front of others, tutors can ask the students to identify a solution for a common health problem, and then asking the above mentioned questions for their responses. In this way, the international students will not be stuck with the standard methods and procedures, but will also gain the ability to critically evaluate each available procedure on its merits and implementation benefits (Yahiro & Saylor, 1994).
Warland (2010) states that critical thinking in nursing is closely related to the self-confidence and experience of the nurses. When nurses are unaware of the different treatment approaches that can be utilized for a particular case, they would not be able to engage effectively in the critical thinking process. On the other hand, experience and confidence comes from more and more exposure to patients, which is a missing factor in student nurses and the recently graduated ones. This would imply that nursing students and fresh nurses would lack in their critical thinking and assessment skills as compared to the ones with sufficient patient care experience. As patient care and proper handling are the most fundamental objectives of any healthcare, the institutions cannot risk it by putting these responsibilities into the hands of the amateur nurses. A solution to this dilemma is by employing “Simulation Activities” as part of the nursing program, in order to better equip the nursing students with the understanding of patient health problems and intervention approach and strategies. The simulation activities can be either high fidelity, for example a dedicated computer programs design to provide visual, auditory cues and feedback, depending on student response, or low fidelity like using a piece of foam to practice giving injections to the patients (Warland, 2010). Using the simulation activities, the tutors will be able to not only bridge the gap between theoretical learning and real-life dealings with patients, but will also be able to bridge gap between nursing from diverse culture, when they will be asked to perform a simulation activity together.
Lessons for Nursing Tutors
Different Learning Styles in Technical Education
Kolb’s Learning Styles Model
The Kolb’s learning model is a good starting point for nursing tutors to understand the different ways in which a student engages in the learning process and develops meaning and understanding from the given knowledge or a practical experience. The Kolb’s model is based on a four-stage process, in which students grasp the information and transfers them to experimentation and critical action planning. These four stages are of (1) Concrete experience; (2) Observation and reflection; (3) Abstract conceptualization; and (4) Active experimentation. Popoola and Hendricks (2014) state that it is essential for nursing teachers to expose nurses to the clinics and hospital settings, where they can learn while observing and reflection. According to Kolb’s model, the first stage of learning is when students experience something and attach concrete feelings and emotions with the experience.
In a study on clinical nurses, Min, Cheng, Chang, and Liou (2013) asked the graduating nurses to work in a very tense environment, enduring work load and other predicaments. After the experiment, the nurses conjoined the feelings of anger and unease with heavy work load and absence of supervision. Min et al. state that when nurses reflected on their experiences, then they were able to make connections with different separate environmental variables of medical facilities, availability of doctors, patient to bed ratio, and other similar variables. Thus, they were able to make a concept of environmental settings that would lead in high work load and mismanagement. This brings them to the next stage of active experimentation, when they develop the capability of changing things in their control and taking notice of procedures and practices in their surrounding in order to improve the patient care setting and ease their work load. Min et al put forward that it is very important that nurses are taken through all this four stages of learning so that they are able to make meaning of the context and develop ability of putting their knowledge and understanding into action. The stage four of ‘Active Experimentation’ has been termed as pragmatism by Popoola and Hendricks, shedding light to the conventional practices of hospitals and clinics. There still exist a number of medical and healthcare centers with loopholes in their patient care, internal communication, and work load division approaches. Using the Kolb’s model, tutors will be able to bring these predicaments into light and enable the nurses to design improvement or adjustment measures with such situations.
Dunns´ Learning Model
Nursing is a practice-based discipline, and therefore, the significance of environmental and social factors into the learning process of nurses cannot be overlooked. According to the Dunns’ Learning model, different students have their different preferences for learning and experimentation, which should be taken into account by the nursing tutor or the administrative department. In a study of 399 nursing students, Bednarz et al found that the majority of the nurses were not comfortable with the supervision provided to them, as they believe that their supervisors eradicate their independence and ability to think differently. On the other hand, few of the students depicted dissatisfaction with the lack of supervision and guidance given to them during their practical experimentation. This suggests that the learning preferences of different students differ with each other, and thus, it is not appropriate to deploy the same teaching and facilitation approaches for all students. Schim, Doorenbos, Benkert, and Miller (2007) further add the cultural factor to this debate. People from different cultures have different cultural values and preferences. Based on Hofstede Cultural Dimensions, people from different culture may differ in their attitude towards individual value and independence, power distance, socialism, and pragmatism (Schim, Doorenbos, Benkert, & Miller, 2007). The natives of Finland are maintain high individual value and on an average are more introvert than the majority of the Asian people. Thus, when Asian students are made to study with the Finns, the teacher has to ensure that cultural factors are also taken into account (The Hofstede Centre, 2013).
Dunn’s model is not limited to the social attributes of learning, but also deals with psychological and physiological elements (Hallin & Bostrom, 2014). Physiological elements include whether the student is a kinesthetic learner or an auditory leaner or a visual learner. Psychological factors include whether a student learns better by doing things or by observing and researching. This highlights that if a teacher uses a monotonous teaching style, a number of students would not be able to learn and understand to their full potential due to the mismatch of their learning style with that of the employed teaching style. Ingham (1991), in his Productivity Environmental Preference Survey of healthcare nurses, found that nearly 40% of the nurses were visual learners, less than 25% were auditory learners, 20% were kinesthetic learners, and around 15% nurses exhibit multi-learning preferences. Based on the Dunns’ learning model, it can be said that nursing teachers have to come out of their comfort zone in order to better understand their students and modify their teaching planners and methodology according to the distinct needs of the graduating nurses (Popoola & Hendricks, 2014).
Teaching Approach to International Nursing Students
It is essential for the nursing tutors to realize the challenges involved in teaching international students as the variance in culture has a significant influence on the learning behavior and clinical practice of the nurses. According to the study by Mariani (2009), the number of local nurses graduated from Finland are not sufficient to provide healthcare facilitation to the entire public, and this opens room for international students to join the healthcare work force of Finland. In the recent years, students from South East Asian countries of China, Philippines, and India etc. have shown their discernible growth in the educational system of Finland. The problems conjoined with such diversification are discussed in the study by Bednarz et al (2010). The study was based on placement problems of international nurses in Finland. Bednarz et al found that the a number of nursing students and fresh registered nurses, when put into the clinical setting, were confused with the different expectations from the patients and the hospital facilities. In many Asian countries, nurses are primarily the assistants of physicians and they are not responsible or allowed to provide treatment measures to the patients. However, in Finland, nurses not only have to work in parallel to doctors, but sometimes they are also expected to work as a substitute of the general physician. This expectation from patients or the hospital management need to be conveyed to nurses so to make them more familiar with their roles in the clinical setting.
Shedding light to cultural differences in Saudi Arabia, Carty, Hale, Rigney, and Carty (1998) state that nursing is one of the intricate professions to adopt as a full-time career for Saudi natives. In the Kingdom of Saudi Arabia, there is a visible gender difference and interaction between male and female students or workers is looked with the eye of insolence and is not appreciated in the local communities. Furthermore, the Saudi natives give high regard to their family time, the night time of a day, and therefore, are reluctant for night shift jobs as it clashes with their family timing. In a pilot study of US and Saudi nurses studying in the Medical University of Riyadh, it was found that Saudi nurses are unwilling to serve male patients, and similarly, there were reluctance in Saudi patients to be handled with the opposite gender nurses. The culture attributes of male-female differences and isolation can also be found in several other Asian and African countries. Since, the culture of Finland is quite different from that of Saudi Arabia or other Asian countries with similar cultural and religious values, there is a high probability of the problems that international nurses would be facing in their clinical practices and dealings with patients or the hospital management. Carty et al. in their study instructed the US students about the prayer timing and other values of the Saudi patients, so that the US students are prior informed about their roles and limitations when placed in clinics or other healthcare facilities. The important thing is that the tutor takes a two-fold approach, where the efforts are made to understand the cultural values and norms of the international students and also making them understand the cultural differences of the local culture.
CHAPTER 3: ACTION PLAN
Simulation Activities
Empirical Evidence
Role play and simulation activities are an interactive way to teach the nursing students about different complication they will have to face in the field. Warland (2010) states that due to capacity limitations and unease of the patient in the presence of multiple nurses, all nursing students cannot be exposed to real life situations until their clinical trial has started. Role play is a strategy that bridges the gap between nurses’ understanding and approaches and the real scenario where their traditional and theoretical approaches will be challenged. Dawood (2013) performed a role play activity with 139 nursing students and found that 69.1% of them enjoyed being part of the activity, and 78.4% and 76.3% responded that role plays helped in improving their self-confidence and communication skills respectively. Owing to these findings, simulation activities can be deemed essential for the current study, which aims to enhance the confidence level of the international nurses and make them better equipped with skills and resources to combat daily challenges they will have to face in their clinical practice.
Role Play
The nursing students should be given the roles of “Nurse”, “Patient”, and “Extra”. The roles of each student should be changed each week so that the students are able to analyze each perspective related to clinical care. It is the responsibility of the tutor to take into account cultural diversity in this activity and make groups in such a way that local students are grouped with the international ones (Warland, 2010). A group will comprise of 3-4 students, where there will be 1 patient, 1-2 nurses, and 1-2 extras. The responsibility of the students designated with extras is to simply observe the nurses, assist them, and do what the nurses ask for general information regarding the patient and his/her health status is provided to the nurses. The students designated as nurses then have to write down their approach of handling the case on a white board, which is provided to each group, so that they have a roadmap about how to deal with the patient.
Each student with the role of ‘patient’ and ‘extra’ is given a cue card, which directs them about how to react when they are been treated or asked to wait by the nurse. (An example of this is illustrated in Table 1 and Table 2). As real patients do not abide strictly to what they have been asked for and are not always very pleasant and easy on the nurses, it is important to bring such situations into practice by creatively designing the cue cards.
The Patient
Background:
You are suffering from chronic disease of diabetes and this is the second time in a month that you have been admitted to the hospital, and you are suffering from low blood pressure and body ache.
Scenario:
The nurse will diagnose the situation and make a note about it. Then she will ask the patient about what he is feeling and what medication he took recently. The patient will not respond to it and keep on saying “I’m fainting, I’m in pain” repeatedly.
The nurse will then proceed towards the blood sample test, but the patient would not allow the nurse to insert the injection, as he is already in pain and start screaming as he sees the needle. He says that “you guys always take my blood and do nothing. Wǒ yào gào nǐ (I’m going to sue you).”
The Extra (Nurse Assistant)
Background:
You are the ward care taker, and your responsibility is to make sure that all beds are clean in the ward and all equipment and tools are placed at the right place. You belong from China, and also speak English.
Scenario:
Commence the simulation by checking all equipment, putting glass of water and other stuff behind patients’ bed, before the nurse come. You can see that the patient is Chinese and aged around 40-45 years.
As the nurse comes and the extra sees that the patient is really frustrated and the nurse is not able to get the blood sample of the patient. She is trying too hard, but could not make the patient relax and also could not understand what he says in Chinese.
Since, the nurse is very senior, you would not want to intervene in her case and depict that you can handle the patient better than the dedicated nurse. However, you are certain that if the patient is explained the procedure in Chinese, there is a better chance for him getting calm and letting the nurses perform the required actions. In this scenario, what should be your approach to simultaneously manage the patient and relation with the senior nurse?
It will be a 15-20 minute drill, after which the tutor will gather all nursing students participating in the activity. The simulation activity will be followed by a 30-40 minute reflection section, where all participants will explain their experience in the scenario, what strategy they opt to handle the medical problem and patient resistance, and what assistance they got from the extra (Warland, 2010). It is also important to ask the patient and the extra about the performance of the nurse and vice versa. In this way, a peer-learning environment can be established, where students will be able to assess themselves and their group mates. This would also benefit their cross-cultural communication skills as they will come across patients or family members, who speak different languages and belong from different cultural backgrounds. In this setting, the international nursing students can be exposed to diverse clinical and medical care facilities, where they have to deal with practical challenges and use their critical thinking and team work skills to manage the situation (Brown & Chronister, 2009).
Computerized Patient Simulator- SimManTM
Learning about health disorders of heart attack and cardiac arrest is quite different than witnessing it in real and preparing measures for its treatment. A nurse work in accordance with a doctor in such high risk and instant care cases, but often when the doctor is unavailable, the nurse should be able to take necessary measures in order to temporarily normalize the heartbeat of patients, providing oxygen masks to the patient, and other pertinent tasks, if required. In order to prepare nurses for such situations, computerized patient simulators have proved to be beneficial. SimManTM is a full body manikin, which includes human-simulated physiologic functions of pulse, respirations, lung sounds, and speech, demonstrated on a computer screen (Durham & Alden, 2008). SimManTM is a high fidelity simulator, where tutors will have a chance to bridge between the theoretical knowledge of the students and its practical implementation. This computerized simulator is equipped with a cardiac monitor that displays hemodynamic waveforms, ECG rhythm, vital signs, and pulse oximetry readings. Thus, for the nursing students, operating a manikin body will be quite similar to that of operating a real patient, as all pertinent functions are present in this software based program. As the students will be able to operate the patient-simulator by their own hands, they will gain confidence and experience of connecting leads and handling patient movement in the process (Durham & Alden, 2008).
EBP for Using Patient Handling Tools
Empirical Evidence
Poor patient handling approaches not only lessens the comfort and safety level of the patients, but also results augment the probability of nurse injuries and muscular problems. For this reason, it is imperative that nurses are aware of different patient handling techniques and are aware of their applications and limitations under different circumstances. Kneafsey & Haigh (2007) conducted a clinical study with 425 graduate nurses on patient handling skills. From the study they found that 85% of the nurses found the drill of using Automatic Ceiling lift to be useful in handling old patients. Another 85% responded that these drills helped them better understand the postural physic of patient for proper placement on bed and chairs. Owing to these findings , drills on patient handling techniques are important for the study in order to assist nursing students and fresh nurses with appropriate method to move and place patients. Due to the language and cultural gap, it is quite likely that nurses are unable to comprehend the level of discomfort and pain of patients, as many patients do not explicitly show that they are uncomfortable with the employed technique (Hignett, 2003). Thus, preparing the nurses with safe and tested handling strategies would lessen the probability of patient discomfort and injury while handling.
Prohibiting Drag Lift Technique
Nurses in many parts of the world use the “Hook and Toss” or Drag Lift technique to manually lift the patient and move from one place to the other. This technique is very common in both American and Asian countries; however, it is not encouraged in Finland and other European countries (Nelson & Baptiste, 2004). For this reason, a drill should be carried out, where the nursing students would be asked to carry out the drag lift approach for lifting a fellow classmate and then reflecting on the predicament they face in using this approach. The tutor will ask a nurse (with heavy body weight) to imitate the patient, who will be lifted by two other nurses. The other two nurses will be asked to perform the drag lift method for moving the first student from a ground level to the bed. After completing this drill, the teacher should ask the students involved in the activity about their experience of this drill. The teacher should ask the following questions from the nurses lifting the patient.
i. Did you feel any back ache while giving the lift?
ii. Were you able to balance the weight of the patient?
iii. Were your hands tightly gripped on the wrist or back of the patient?
iv. Did patient was properly shifted to bed?
Furthermore, the tutor should ask the following questions from the patient.
i. Do you feel any back ache or other pain in your body while you were given the lift?
ii. Were the hands of the nurses hurting your back, wrist, or shoulders?
iii. Did you experience any sort of pain after you were transferred to bed?
This discussion should be done in a class, while other students can listen to the responses of both the patient and the nurses involved in the activity. The same activity can be done with a nursing student of light weight to see if the same results come. It has been found in a number of studies that continuous use of this method can be a cause of back injury for the care giver as well, not to mention the stake so back and other injuries it causes to the patient (Hignett, 2003). Once, the tutor is able to make the students realize about complexities and problems conjoined with this handling approach, s/he should shed light on better patient handling approaches.
Use of Automatic Ceiling Lift versus Transfer Board
After establishing the drawback of the drag lift approach, the tutor should now introduce improved methods for lifting and moving patients. As this method employ modern technology, it is essential for tutors to first introduce the basic mechanism of the device for the international nursing students, who might not be familiar with such devices. Students should be brought to the medical lab, where there is a ceiling lift and a transfer board available. All nursing students should be divided into a group of five, where three students would imitate as patients, while two students would have the role of nurses. Each group will be given 10 minutes to transfer the three patients from bed to wheelchair, from ground to bed, and from wheelchair to bed respectively, using either the transfer board or the automatic ceiling lift. The tutor will give instructions about which method they have to employ for the three patients. The teacher will make the following flash cards and will distribute it into the groups (ACC.CO, 2012).
Lift from bed to wheelchair using automatic ceiling lift.
Lift from ground to bed using automatic ceiling lift.
Lift from wheelchair to bed using automatic ceiling lift.
Lift from bed to wheelchair using transfer board.
Lift from ground to bed using transfer board.
Lift from wheelchair to bed using transfer board.
The students will be given one flashcard from category 1 and 2 from category 2 or vice versa. After completing the drill, the students will be asked to give their reflection on each of the three lift exercise and which of them the found to be the most difficult or easy. The students should reflect on the following questions.
i. Which lifting method was the most intricate and why?
ii. Which lifting method takes the most time?
iii. Does weight of the patient affects the applicability of transfer board method?
iv. Does weight of the patient affects the applicability of ceiling lift method?
v. What problems occurred in the three situations of patient lift?
CHAPTER 4: ANALYSIS OF ACTION PLAN
As addressed in the literature section that international nurses are uncertain of the common behavioral patterns of people, and therefore, face difficulty in handling them and communicating with them. In the role play activity, international students will get a chance to act as nurse assistants, in-charge nurses, and as patients. Through repeated observations and judgment skills, they will be able to incur the understanding of common nurse-patient and nurse-nurse issues, and the strategies of handling them. Dawood (2013) finds in his study that undergraduate nurses, who were involved in the role play activities, were more confident in patient handling and communication tasks than the ones who were just theoretically taught about these tasks. Often nurses are assigned with the tasks of resource management and assisting the dedicated patient nurse. For this reason, they do not get a chance to directly interact with the patients or their family members. Thus, when such situations come when they have to directly deal with the patient or their family members and calm their nerves, their lack of experience get the better off their communication and management abilities. Simulation activities with computerized manikin or role plays would help the nurses to retain their patient handling and care skills, who are isolated from direct patient handling for a long time.
There are a number of methods for patient handling and placement, but no one method can be considered universal or fit for all purposes. Nursing students coming from other cultures are used to of traditional patient handling practices, which expose both nurses and patients to health risks and injuries. These evidence based drills would enable the nurses to understand the application and limitations of each handing method and analyze whether the chosen approach is the most suitable one for the patient or not. Fragala and Bailey (2003) mention that lifting patients and moving from bed to chair or from chair to bed requires different muscle movement. A number of lifting and handling tasks require more than one nurse, but since nurses are not aware of the complications that may occur; they advance to give it a try. This EBP handling activities will help nursing tutors to assist both local and foreign nursing perform this activity, they will be in a better position to comprehend the handling situation as per the body weight and physical status of the patient, and can make rational decisions accordingly (Kneafsey & Haigh, 2007).
CHAPTER 5: CONCLUSION
It can be concluded that the international nursing students have to develop a variety of skills pertinent to their nursing profession in order to adjust with the clinical setting and patients’ expectations in Finland. One of the primary criteria for survival for the international nurses is to get command over the primary language of Finnish and also learn basic healthcare related sentences of Swedish, as it is the second widely spoken language in the country. Furthermore, the international nursing students should try to make peers with the local students in order to better understand the societal culture and general religious and psychological norms practiced in the country. Only when the nurses would have developed the understanding of their patients’ psychology and family and work history, they will be able to diagnose the ethology of the problem. The nursing students can take aid from a number of online and offline interpreter tools in order to convey their message to the patient and also decoding their message, if spoken in a different language. As Finland is growing more and more diversified, nurses have to be prepared for confronting the cultural and linguistic problems in their career. They are required to take the cultural difference of their patients positively and try to communicate with them as much as possible through the available resources in order to get a better insight of their physical and psychological condition. The patient explanatory model presented in the study also elucidates the fact that learning patients’ perception and psychology about a health problem can help the caregivers in reaching and eradicating the root of the problem.
The significance of EBP has also been discussed in the study and conjoined with the healthcare procedure of patient handling and lifting. As international nursing students are new to the environment, they are less capable of differentiating between regulations and local standards. It is important that nurses employ critical thinking approach to ensure that the medical approach used by them is effective and does not pose any harm to their health or the health of the patient. In patient handling, a number of approaches can be used like slide sheets, transfer boards, and ceiling lift etc. However, every approach has its own benefits and limitations, pertinent to different types of cases. The nurses are required to analyze the case and then adopt a care approach, rather than assuming one approach to be standard and fit for all cases. The series of activities designed in the Action Plan aims to assist new and old nursing students in their critical thinking about patient handling and care strategy, so that the nursing students can learn that which strategy can be used at what circumstances and what can be its possible stakes. In addition to this, ACE Star Model of Knowledge Transformation also elucidates the critical thinking and implementation approach of the nursing practitioners. Before integrating any medical approach, the nurses should have relevant knowledge about it, whether it abides by the regulations or not, and whether it is the best approach under the circumstances or not. When all these information is gathered and analyzed rationally and critically, the finalized approach will be refined and will have fewer chances of inaccuracy and or flaw.
References
ACC.CO. (2012). Equipment for moving and handling people. New York: ACC.CO.
Bednarz, H., Schim, S., & Doorenbos, A. (2010). Cultural Diversity in Nursing Education: Perils, Pitfalls, and Pearls. Journal of Nursing Education, 49(5), 253–260.
Brown, D., & Chronister, C. (2009). The Effect of Simulation Learning on Critical Thinking and Self-confidence When Incorporated Into an Electrocardiogram Nursing Course. Clinical Simulation in Nursing, 5(1), e45–e52.
Carty, R., Hale, J., Rigney, D., & Carty, G. (1998). Teaching international nursing students: Challenges and strategies. Journal of Professional Nursing, 14(1), 34–42.
Cioffi, J. (2003). Communicating with culturally and linguistically diverse patients in an acute care setting: nurses’ experiences. International Journal of Nursing Studies , 40, 299–306.
Conner, K., Copeland, V., Grote, N., & Koeske, G. (2010). Mental Health Treatment Seeking Among Older Adults with Depression: The Impact of Stigma and Race. Am J Geriatr Psychiatry, 18(6), 531–543.
Dawood, E. (2013). Nursing Students’ Perspective about Role – Play as a Teaching Strategy in Psychiatric Nursing. Journal of Education and Practice, 4(4), 38-48.
Durham, C., & Alden, K. (2008). Enhancing Patient Safety in Nursing Education Through Patient Simulation. In C. Durham, & K. Alden, Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Cambridge: Brooks Publishing Limited.
Evans, C., & Stevenson, K. (2011). The experience of international nursing students studying for a PhD in the U.K: A qualitative study. BMC Nursing, 10(11), 1472-1481.
Fragala, G., & Bailey, L. (2003). Addressing occupational strains and sprains: musculoskeletal injuries in hospitals. AAOHN Journal, 51(6), 252-259.
Gerrish, K., Chau, R., Sobowale, A., & Elizabeth, E. (2004). Bridging the language barrier: the use of interpreters in primary care nursing. Health and Social Care in the Community 12(5),, 12(5), 407–413.
Hallin, K., & Bostrom, L. (2014). Learning Style Differences between Nursing and Teaching Students in Sweden: A Comparative Study. International Journal of Higher Education, 2(1), 22-34.
Hignett, S. (2003). Intervention strategies to reduce musculoskeletal injuries associated with handling patients: a systematic review. Occupational and Environmental Medicine, 60(9), 1-8.
Hirvensalo, E. (2006). Legislation covering medical malpractice in Finland. Journal of Bone and Joint Surgery, 88, 13-14.
Jakubowski, E., & Busse, R. (1998). Healthcare system in the EU: A comparative study. Luxembourg: European Parliament.
Jones, E. (2010). Internationalisation and the student voice: higher education perspective. London: Routledge.
Klauer, T., & Filipp, S. (1993). Stress and coping resources: Theory and review. Gottingen : Hogrefe.
Kneafsey, R., & Haigh, C. (2007). Learning safe patient handling skills: Student nurse experiences of university and practice based education. Nurse Education Today, 27(8), 832–839.
Kokko, S. (2009). Integrated primary health care: Finnish solutions and experiences. Int J Integr Care, 9, 593-597.
Luxury Care. (2012). Luxury Care: Case Studies. Retrieved November 4, 2014, from Luxury Care: http://www.luxurycare.co.uk/dementia-case-studies/
Malecha, A., Malecha, C., Tart, K., & Junious, D. (2012). Foreign-Born Nursing Students in the United States: A Literature Review. Journal of Professional Nursing, 28(5), 297–305.
Mariani, G. (2009). Foreigners Studying Nursing in Finland: A Study about Experiences from Practical Placements. Ankara: Turku University of Applied Sciences .
Nelson, A., & Baptiste, A. (2004). Evidence-Based Practices for Safe Patient Handling and Movement. Online Journal of Issues in Nursing., 9(3), 172-188.
Oermann, M., Harris, C., & Dammeyer, J. (2001). Teaching by the nurse: How important is it to patients? Applied Nursing Research, 14(1), 11–17.
Popoola, S., & Hendricks, C. (2014). Learning Styles of First-Semester Baccalaureate Nursing Students: A Literature Review. Institute for Learning Styles Journal, 1, 1-10.
Prospects. (2012). Case studies. Retrieved November 4, 2014, from Prospects.UK: http://www.prospects.ac.uk/case_studies_paediatric_nurse_case_study_1.htm
Putsch, R., & Joyce, M. (1990). Dealing with Patients from Other Cultures. In K. Walker, D. Hall, & W. Hurst, Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworths.
Rautakoura, A. (2012). Foreign nurses in Finland face difficulties. Retrieved November 4, 2014, from Helsinki Times: http://www.helsinkitimes.fi/themes/themes/working-life/4375-foreign-nurses-in-finland-face-difficulties-2.html
Riley, M., & Fearing, A. (2009). Mentoring as a teaching learning: Strategy in Nursing. Measuring Nursing, 18(4), 228-233.
Schim, S., Doorenbos, A., Benkert, R., & Miller, J. (2007). Culturally congruent care: Putting the puzzle together. Journal of Transcultural Nursing, 18, 103–110.
Schulenburg, J., & Blanke, M. (2004). Rationing of Medical Services in Europe: An Empirical Study : a European Survey. Amsterdam: IOS Press.
Singh, C., Sharma, S., & Sharma, R. (2011). Level of stress and coping strategies used by nursing interns. Nursing and Midwifery Research Journal, 7(4), 152-160.
Stevens, K. (2013). The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas. The Online Journal of Issues in Nursing, 18(2), 34-41.
The Hofstede Centre. (2013). Finland. Retrieved October 29, 2014, from The Hofstede Centre: http://geert-hofstede.com/finland.html
Walker, K., Hall, D., & Hurst, W. (1990). Clinical Methods. Boston: Butterworths.
Warland, J. (2010). Using simulation to promote nursing students learning of work organization and people management skills. Sydney: University of South Australia .
Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 11, 351-356.
Yildirim, B., & Ozkahraman, S. (2011). Critical Thinking in Nursing Process and Education. International Journal of Humanities and Social Science, 1(13), 257-262.
TO GET YOUR ASSIGNMENTS DONE AT A CHEAPER PRICE,PLACE YOUR ORDER WITH US NOW