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Nazareth • • • •
Largest city in the North of Israel “The Arab capital of Israel“ Population : 210,000 59% are Israeli Arabs – 68% Muslim – 31% Christian • 41% are Jews
(Israel Central Bureau of Statistics 2009) 1
The Nazareth Hospital • Known locally as 'The English Hospital‘ • Based in Nazareth, in Northern Galilee • Serves a predominantly Arab population within the multicultural, multi-ethnic society of Israel without distinction, regardless of religion, community or political affiliation. • Operates a 24 hour A & E department and delivers a full range of hospital and community based services.
Nazareth Hospital Vision and Values
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Nazareth Hospital The Nursing Programme • The only Arab-Israeli school within Israel that offers an RN diploma program • Dr Amal Khazin is Director of Nursing Education
• To learn more about the history and work of the Nazareth Hospital EMMS in Israel see: • http://www.youtube.com/watch?v=AiE53MgM1Vs
• Since 2010 the RN nursing program has been affiliated with Haifa University to offer a nursing degree program. • Students alternate between Nazareth and Haifa campuses
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Nazareth Hospital Teaching Team
Student Placements in Israel
Hadassah Mount Scopus, Jerusalem
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Initiation of the Project • Dr Amal Khazin anticipated that an exchange project would – ‘…. broaden perspectives, change thinking, facilitate acceptance of differences, ‘make peace with others and self’, and increase student motivation to study and ‘do something different’. • Initial discussions took place between Dr Amal Khazin and Pat Bradley (responsible for overseas partnership development in the School of Nursing, Midwifery & Health) regarding the logistics of the student exchange project.
Rambam Hospital, Haifa
Ha’emek Medical Centre Afula
Haddassah Ein Karem
Tel Hashomir, Tel Aviv
Netanya Hospital 8
Goals of Project The project was anticipated to: 1. Assist students to observe • a different system of health-care • how evidence-based practice / quality improvement is integrated • how professionalism is expressed
2. Increase awareness of the impact on the delivery of healthcare of different: • political drivers • professional regulators • social influences
3. Create opportunity to establish cross-cultural professional relationships 10
Approval of Project by School of Nursing, Midwifery & Health • Project approved by Professor W Lauder, (then) Head of School of Nursing, Midwifery and Health, University of Stirling • Ensures an international dimension in the BSc Nursing (Adult) programme • Meets the QAA’s broad aim of supporting the ‘Internationalising of the curriculum’ http://www.quality.stir.ac.uk/learnteach/Section2.php#Five
Approval of Project by NHS Highland • Proposal submitted to Ms Heidi May, Board Nurse Director, Raigmore, NHS Highland • Proposal approved – Each year three 3rd year nursing students from the Nazareth Hospital will spend three weeks in an observational placement at Raigmore Hospital.
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Reciprocal Arrangements
Funding for Accommodation
• Free accommodation and meals for
• Proposal submitted to Stirling Enhancement of Learning Fund (SELF) 2013
– University of Stirling students on the Nazareth Hospital compound
• Proposal accepted – Nazareth students in Raigmore accommodation
• Award of £1000 helped to cover cost of subsistence and accommodation on Raigmore site for Phase 1 of student exchange
• Students only need to fund – Flights – Cost of tourist activities 13
The Exchange Students’ Introductions Rajaa’ Hanna
Rani Odeh
Narmin Mustafa
22 years old, family of 4 siblings
23 years old, family of 2 siblings
26 years old, family of 4 siblings
Christian Arab
Christian Arab
Muslim Arab
Nazareth, Israel
Kfar Yassif, Israel
Nazareth, Israel
Starting my 3rd year of Nursing in September
Starting my 3rd year of Nursing in September
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Organisational Issues Proposal for Nazareth students to have an elective placement in Raigmore Hospital approved by School of Nursing Midwifery and Health NHS Highland
Goals approved and benefits acknowledged Nazareth students selected and prepared … Funding secured for students’ accommodation/ meals ‘Buddies’ and placements identified Ward Manager approval Surgical Division approval William Craig-Macleman (Acting Divisional Nurse Manager Surgery and Anaesthetics Division)
Starting my 3rd year of Nursing in September I have first degree in genetic engineering. 16
Organisational Issues Buddy/Mentor preparation Nazareth Student introductions to ’Buddy’ & Mentor Observational capacity Criminal Record screening Occupational Health Confidentiality Honorary contracts
Uniform & identification Letters for Immigration by Heidi May Amal Khazin Annetta Smith
Induction programme Clinical supervision plans Media & Press Releases Pre-placement evaluation Post-placement presentations 18th July 2013
Donald MacLeod (Assistant Nurse Manager for Surgical and Anaesthetics Division)
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Briefing Leaflets
Nazareth Students Arrive in Scotland
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Induction Programme
Hopes and Fears
• Special thanks to: – – – –
1. Cultural/Environmental Language, Food, Weather Cultural experience Sightseeing…
Ellen-Anne Novak Stephen Loch William-Craig MacLennan Laura Greenshields
2. Nursing: Nursing/Medical Terms in English New/Different Cases Observational Shifts 12 hour Shifts…
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Nazareth Students with their Buddies
Media & Press Releases
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Media Interest Mentors
‘Buddies’
Nazareth Students
3C RN Morag Reid Gillian Fyvie
Rani Odeh
4C RN Audrey Taylor/ Diane Morrison
Sarah Smith
Rajaa’ Hanna
5C RN Janet Small/ Eilidh Brooman
Emma Peacock
Narmin Mustafa
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Clinical Skills Day on Highland Campus
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A Cultural Experience!
Thanks too to Peter White and Wendy Jessiman for including the Nazareth students in the semester 6 clinical Skills Day
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Exchange Student Presentation • ‘Eyes had been opened’ to many new aspects of nursing including: • • • •
• Hand over + Nursing Reports • Medicine Cabinet and Medicine Storage • Thermometer • Forms [Vital Signs and SEWS...] Waterlow Scale for pressure sores [Norton Scale] • Plastic Aprons • 12 hour shifts • More Staff members, less stress • Encouraging Patient Independence • Gloves during IV Medicine preparation • Cannulation • Medication [Name, DoB, CHI #]
Evidence-based practice Quality improvement. Patient-centred approach. Level of communication / relationships between professional and patient.
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•Technique for cleaning Skin • Patient Notes potentially accessible by anyone • Patient Name boards • All IV Medication needs double checking [2 nurses] • Giving out Meals and making beds • Nursing Diagnosis (NANDA) • No Bursary [Placements, accommodation, transportation] • NHS versus Kopat Holim (Klalit etc) • Care given to Patients [Time] • Relationship with Consultants 30
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Evaluation of the Exchange Project
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Evaluation of Phase 1
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Likert Scale and Open Questions
Nazareth Students 1. Pre Placement Questionnaire 2. Post Placement Questionnaire 3. Joint Presentation at end of placement Buddies 1. Post –placement Questionnaire Mentors 1. Post-Placement Questionnaire 33
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Interview with Rajaa’ Hanna April 2014 (9 months later)
Response Rate • Nazareth Students – 100% (n3) • Buddies – 100% (n3) • Mentors – 66% (n2)
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Unintended Outcomes
What they thought about the Scottish model of nurse education
• Extreme stress for exchange students due to – Timing of Exchange placement – Piecemeal approach re documentation for completion/ translation
• Struggle with a different ‘world view’ /perspectives on nursing care and the dis-ease with the significant differences in nursing education and nursing practice between the two cultures • Lack of compliance with 12 hour shifts and subsequent erratic attendance on placement
• “I think that the Scottish model of nurse education contain a lot of social and communication courses more than the courses that learn about disease and the body systems. It’s a good thing but I think that it’s important also to know all of the things about the patient like the disease that he has and about the medicine he takes”. • “I think that it has a lot of essential courses that are important for students to learn and achieve in order to become the nurses that the Hospitals need. I also noticed that it doesn’t include many teaching about the medical things which makes it hard for the nurses to speak to the Doctors on the same level”.
• Discomfort with the dissonance between the two programmes • Resistance to a paradigm shift; they did not seem ‘ready’ to embrace the cross-cultural aspects of health care delivery or to enter fully into the experience 37
What they thought about the Scottish model of nurse education
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Key Comments
• “I think that it is good in the sense of having a lot of self study material so students have to look for answers themselves! On the other hand I feel like the Israeli programme emphasises also on medical studies and not just nursing. So a nursing student would be expected to know some of the (theory) just like the medical students”.
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“ One of the things that stood out to me most during the placement is the friendship between the staff and the patients. The care, the attention, the time they spend with a patient is amazing. I do think that it influences the patient’s health positively. So that, I would like to develop here in my work at the Nazareth Hospital”.
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Would they recommend an Exchange Visit to other students?
Ideas for cross-cultural research
• “I will recommend this exchange visit to other students because there is a lot to learn, also because it is a once in a lifetime experience”.
• “The effect of the cultural difference on the patient care and treatment”.
• “….. it was a very influencing and important experience in my life that will add in the final shaping of the person I’m becoming”.
• “The difference between circular and linear cleaning with alcohol before insertion of the needle”. • “…..I would like to know if and how the time that is spent with the patients influences their health positively”.
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• “I would recommend this exchange because it is of great value both personally, culturally and most important professionally. It is a learning experience and sometimes challenge for both sides, which is a good thing for the health care giving system”. • “Professionally: I have learned a lot from this project. Things to improve, things I’ve never seen or thought of before, challenges and achievements.
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Experiences arranged by Buddies
Buddy Evaluation
Buddy 1
Buddy 2
Buddy 3
• Time spent with
• • • •
• Routine observations • MRI Scan • ERCP • Theatre • Pain nurse • Nurse practitioner • CT scan • X-ray • Wound dressings
– Pain Nurse – Urology specialist – Vascular nurse clinic
• Dressings • VAC therapy observations • Lavages • Medicine rounds • Documentation • Personal care • Person centred care
• • • •
Plaster room Pain nurse Theatre experience Caring for orthopaedic patients Dressing changes BM + obs Pressure area care (anticipatory care nursing) Care of unwell patient “
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“Knowledge Exchange” Scotland teaching Israel..!
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Buddies impressions of the Israeli System..! • “More centred around skills than delivery of person centred care. Very task orientated and strict training regimes”.
• “SIGN and patient safety initiative • PVC bundles and collecting data of statistics of infection
• “Surprised at how little personal care there is but believe a high level of well educated nursing is delivered in Israel.”
• IHI • Research based practice”
• “Less emphasis on patient care and the patient as an individual and more emphasis on their medical condition”.
• “Importance of evidence-based practice! Reason why we use certain materials/ dressings, have certain charts to fill in”.
• “They are trained to a higher standard with regards to medical knowledge and their role is not unlike the junior Dr role here. They have a more in depth knowledge of A+P and associated conditions and medications”.
• “How we search for information using journals and then use this to influence practice.” • “NMC, local ward policies”. 45
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One buddy’s ideas for international/cross-cultural research
Comments from Buddy 1
“Whether having the extra knowledge the students have, makes them better nurses and reduces mortality rates as I believe they would be able to recognise a deteriorating patient quicker and deal with it more effectively.”
• “A good experience overall. My student thoroughly enjoyed it. Nice to hear different ways of doing things and to be commended for certain things. Interesting and very pleased to have done it! My ward was very supportive and helpful.”
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Comments from Buddy 3
Comments from Buddy 2 • “I felt the students did not benefit from this experience as much as I thought and as much as they thought. More specific learning outcomes and maybe a mini OAR detailing what they would like to learn may have been more beneficial as well as keeping a record on their hours.”
• “I found the first week good however the second week the student wasn’t very interested and didn’t want to be there.... .....They also were having conversations in Arabic in front of us which made me feel uneasy..........” • “I did not feel they were respectful of our culture but they expected us to be of theirs............I felt it was a waste of my time as I was trying my best to provide her with good experience but in return found her disrespectful, rude and not interested……….”
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Would buddies recommend being a buddy to an exchange student?
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Unintended Outcomes for UoS ‘Buddies’ • Apparent lack of interest of Nazareth students at times to engage with the planned experiences
• Two of the buddies would recommend it
• Challenge of not knowing as much of the medical/ pathophysiological /pharmacological detail as the Nazareth students appeared to be cognisant of
• One would not ‘because of the language barrier”
• Difficulties of the Nazareth students not adhering to the 12 hour shifts, erratic attendance & apparent lack of interest at times
Project Lead’s Comment: This comment was not based on language difficulties but rather on frustration with other characteristics/behaviours/ cultural differences of the exchange students.
• Very negative feelings expressed by one buddy who was incensed at the cultural insensitivities displayed
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Mentors’ Perceptions of Exchange Visit
Mentor Evaluation
• Exchange Visit not perceived to be of value to the Exchange students • Varying points of view on: – – – – – – – 53
Benefits of Exchange placement Burden of supporting both buddy and exchange student Extent of increase in cultural awareness experienced Not learned much about a different healthcare system An ‘unfair burden’ on the buddy Observational placement of less value than if ‘hands on’. May be better if a mentor ‘buddied’ 54
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Issues resulting in negative impact • Exchange students were at the end of their 2nd year rather than the 3rd year as originally agreed • Were the aims of the Project unrealistic for 2nd year students in a 3 week placement? • Would it be of more benefit for a mentor to supervise the Exchange Student rather than a ‘buddy’ (a mentor’s suggestion) 55
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Lessons Learned: Pre-Placement
Lessons Learned: In-Placement
• Maintaining communications during the preparation process needs time and organisation • Exchange students should be in the final year of their programme • Timing of Exchange visit crucial to students and buddies – should not conflict with pressure of exams or final placements – more time needed for preparations
• Pre-placement documentation needs to be sent in a package at least 3 months in advance • Cultural preparation is required 1. 2.
• Professional support should be offered to ‘buddies’ throughout the 3 weeks • 12 hour shifts are too long for an observational placement minimum hours to be agreed • A mini OAR (On-going Achievement Record) would help the Exchange students to validate their experiences • A daily ‘conference’ with the Exchange Students should be planned to : 1. 2. 3. 4.
even for the seasoned Israeli traveller with good English..! for the host buddies as some of their reactions were due to their misunderstanding of the way Arab-Israelis communicate
Discuss clinical experiences Monitor level of engagement, interest and attendance Ensure development of cultural awareness Facilitate exploration of feelings and reactions
• Goals of project need to be clear to Buddies & Exchange students • Better preparation in relation to the various models of nursing 57 education
Lessons Learned: In-Placement (cont) • More opportunity for buddies and exchange students to compare and contrast the different healthcare systems objectively and enable them to appreciate the ‘social’ model versus a ‘medical’ model of health care delivery without either party feeling undermined
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Maclean G (2013) Electives and International Midwifery Consultancy : a resource for students, midwives and other healthcare professionals. London: Quay Books • This recent addition to the literature on elective placements provides enormous insight into the problems and pitfalls of elective placements as well as the personal enrichment they offer if undertaken with the right attitudes. • ‘Softening the touch-down experience of re-entry’ (p223) is of particular value
• Need to develop cultural understanding of each others’ sensitivities, eg what is acceptable / unacceptable behaviour in the different cultures both professionally and socially
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“Softening the Touch-Down”
Phase 2 • Two University of Stirling students have recently returned from a 3 week placement in the Nazareth Hospital in April 2014 where they observed the delivery of healthcare within the multicultural, multi-ethnic society of Israel (yet to be evaluated)
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Key Messages for Others engaging in Exchange Placements
Future Work • Preparations for four Nazareth students to come on an Exchange Visit to Raigmore in July 2014 are underway
• For an exchange placement to be effective an enormous amount of preparatory and on-going work is required
• Continuing evaluation will help to identify if the Exchange Project is worth pursuing/ sustainable long-term. This will take the form of a questionnaire to assess the long–term benefits to the exchange students one year after their visit.
• Further experience and evaluation will tell if this Project – is able to achieve its goals for students and sending institutions both professionally and personally – is worth the effort!
• Implementation of the ideas for research will also help to identify the value of the project. 63
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Thank you for listening! Any Questions/ Comments/ Advice?
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