Becoming a UK Registered Nurse
** note this was written in 2017 and the testing has changed since I completed my test. Please make sure your up to date with those specific test requirements *
If becoming a UK registered nurse is something that you have always dreamed about then I want to shed some light on the entire process to help you decide if it's really something you want to do. The year I was a brand new nurse completing a postgraduate paper at the University of Auckland as part of the Nursing Entry to Practice Program (NETP) I decided that I wanted to work as an emergency nurse in London. Our lecturer Kiri Matiatos was something of an inspiration to me having worked in a London Emergency Department (ED) and then now working at Auckland Hospital ED. She had the years of experience and knowledge that I wanted NOW and didn't want to have the continued feeling of incompetence as I moved around the different areas of ED myself not knowing what I don't know. I had seen the TV show '24 hours in A&E' which is based out of Kings College Hospital in central London which only sparked my interest further. I knew that as soon as Lewis and I started talking about moving to the UK for a couple of years there was no way I was going to do anything other than continue my career as an emergency nurse and keep gaining that knowledge and experience I craved. I contacted an agency called 'Continental Travel Nurse' in October 2016 which was a company one of my colleagues introduced me to a few years back as she was looking to head to the UK herself. I had a lovely recruiter called Amy who I spoke to on the phone and sent many emails to in order to gain an idea as to what was required to get registered in the UK. I can tell you it is quite the process but I jumped in head first oblivious to the hard yards ahead and not knowing what other options I really had other than taking some time off nursing and working as a nannie. A lot of my colleagues at Middlemore ED thought I was crazy going through this process and I even had friends from nursing school currently over in the UK who didn't get their UK registration due to the hassle of it all. I was too far in to quit by this stage and promised myself I would be one of the ones that made it through.
Step 1: IELTS Exam
Cost: $385 NZD (£203)
The first step for me was to book the English language exam called the IELTS (International English Language Testing System) despite having only spoken english my entire life and completing a degree as well as a postgraduate certificate all written in english it was still a requirement. I had to book the academic version of the exam as opposed to the general one which cost me a total of $385 NZD . The Nursing Midwifery Council (NMC) in the UK is very specific as to what score you get in order to get to the next step of your application. There are four different sections - reading, writing, listening and speaking and you must get at least a 7 out of 9 in each category. The speaking is the easiest as I just had to talk about topics that the examiner gives to you. For the writing you are given a graph or a picture and you need to write about it up to a certain word count. Reading you are expected to read three articles and then answer up to 15 questions on each of them to a total of 40 questions. For the listening section a tape recorder plays and you have to fill in the blank section or chart. The website offers some practice questions for each of the sections and I was surprised by how hard it all was! The exam was an all day thing that I sat on December 3rd 2016 but post exam I was spoilt to be taken to the Coldplay concert at Mt Smart Stadium with Lewis's family. If you are trying to get your UK nursing registration now you will be pleased to know that as of November 1st 2017 the NMC has decided to change the requirements of the IELTS exam and if you have completed a undergraduate degree in english or you have been registered and practicing nursing for a year in a country whos first and native language is English then you no longer need to sit this exam. Yay!
Step 2: NMC Part 1 exam
Cost:
Exam $231.93 NZD
Additional costs: flights + accommodation + parking to get to Wellington $250 NZD, Study material $40 NZD
TOTAL cost: $522 NZD (£275)
Now the real work begins since everything from now on is nursing specific and you feel a little as though you are haemorrhaging money to the NMC. First you need to get onto the NMC website and begin your application for nurses trained outside of Europe. You won't be required to upload any documents at this stage but they will send your details through to Pearson Vue who are the company in which you take the NMC part 1 exam with. If your living in New Zealand there is only one test center unfortunately and this is in Wellington. To be fair it's not really in Wellington like I thought it's in Lower Hutt in the suburb of Petone at Wellington Institute of Technology. If your wanting to make a bit of a trip out of it there is always multiple test centers in Brisbane, Sydney and also Melbourne! I sat my exam on April 3rd 2017 which was a bit later than I hoped but I went traveling to Iceland with the NZ Womens Ice Hockey Team for World Champs in February and also had a couple of weeks off around New Years at the lake and the beach with my family. I wanted to give myself a good amount of time to prepare and also had to request a weekend off from work since we decided to have a few days in Wellington over the weekend before I sat the exam on the Monday morning. I heard back that I had passed basically half a day later when we were back in Auckland that night which was very quick!
The test is a computer based exam which is multiple choice and consists of 120 questions based on professional values, communication and interpersonal skills, nursing practice and decision making, leadership management and team working, and general medical and surgical questions. The exam length is 240 minutes but I shot through it a lot quicker than that and was out in about 90 minutes. They say that you should leave about 1-2 months for study before your exam date but I can honestly say that a month will be more than sufficient. The main way I studies for this was to go through whats called the "NMC nursing blueprints". They include the four different domains below which you can click and it will take you to them. There is also links at the bottom of each domain which you should open and look at briefly - majority of them, don't actually work so don't stress! Just make sure that they haven't been updated on the main website: https://www.nmc.org.uk/registration/joining-the-register/trained-outside-the-eueea/adult-general-nursing/
Domain 1: Professional values
Domain 2: Communication and interpersonal skills
Domain 3: Nursing practice and decision-making
Domain 4: Leadership, management and team working
The other main way that I studied for this exam was through an app on my phone which allowed me to study a lot more whilst I was out and had a short amount of time to kill. BMJ onexamination (British Medical Journal) specifically designed this website/app for nurses trained outside of the Europe seeking employment in the UK. It provides 300 multi choice questions that focus on everything that is potentially going to be tested in the NMC part 1 exam. You can buy the subscriptions for either 1,2 or 4 months and I can highly recommend this. Especially if your anything like me and its been three years since I sat my State exam (registration exam in NZ) in which I would have been studying similar things and it is daunting to get your head around what you need to study and in what depth. Here is the link for you to download this if you like http://www.onexamination.com/exams/worldwide/nmc-part-1#QuestionBrowser. I was also given a list of topics in the exam by my agency to help study around these topics so I will give you this list also: MRSA, depression, stages of grief, patient centered care, canes/walkers, delegation, roles of a nurse, primary care, infection control, digoxins interactions with other major drugs, diabetes, basic drug calculations (fluids and tablets - not using a calculator as you are not allowed one in the exam), pain ladder, end of life care, what is the NMCs role, dementia, confusion.
Step 3: Paperwork, paperwork, paperwork...
Cost:
Application fee $263.27 NZD
USA FBI police check $120 NZD
NZ Police check - free!
Christchurch Polytechnic Institute of Technology (now ARA) for transcripts $50 NZD
Verification of good standings form from the Nursing Council of New Zealand (NCNZ) $70 NZD
GP appointment $18
Application postage track & trace from Auckland, NZ $41.59
TOTAL: $562.86 NZD (£296)
This is probably the most frustrating step of all and despite me being fairly onto it it still took me 2 months to complete this. The NMC is very specific about how the forms are filled out which is why it is such a headache so make sure you give yourself enough time to do this BEFORE you get yourself to the UK, infact I would recommend not leaving for the UK until you have got the all clear back from your paperwork and are free to book in for your NMC Part 2 exam. However, I do have numerous friends on visas longer than mine (I'm on the Tier 5 Youth mobility Visa for two years) and they are trying to complete their application whilst they are over here in the UK working in a non nursing job. So an overview of what you need to complete this step. You will have to complete the NMC online application as well as send paperwork into them. Be aware that the police checks must be from within the last three months so that was the thing I left until last to ensure that it wasn't expired by the time I got all my other paperwork together.
The online application consists of:
Uploading a copy of your passport
IELTS results (if required)
Entering how long you have been in education prior to university (ie high school)
Uploading a copy of your Nursing Degree
Upload your first registration certificate and your most recent certificate (for every state/country you have worked in)
Upload a copy of police checks from every country you have lived in since age 18 (must be national checks and not just state checks)
Because I worked for just over 3 months in America in 2011 on a ski field there was a chance that the NMC was going to want an FBI police check. Therefore I had to go through the painful process of getting one that involved filling out a form online, getting my fingerprints taken at a local post office and then waiting about 4 months for this to come through. It cost me at extra $120 NZD and was never required by the NMC but it could have delayed my application for months if they did want it.
Complete the good character section tick boxes
NOTE: Once the paperwork is printed it cannot be rescanned or photocopied due to the barcodes on it and the NMC must receive the originals. You can download it off the website, email it through to your university etc but as soon as they press print that is what needs to go to the NMC. Although before you send it take a copy for your own records.
To be completed and sent into the NMC:
By the University/Polytechnic that you attended :
Cost: $50 from Christchurch Polytechnic Institute of Technology (now ARA)
The "Summary of transcripts form" which basically breaks down all the hours you spent in different specialties during your degree.`
Transcripts - BUT these have to be converted from credits into hours by the university.
By the nursing board you have been working under (ie NCNZ for New Zealand nurses)
Cost: $70 NZD by the Nursing Council of New Zealand (NCNZ)
The "verification of good standings" form
Note: Sometimes the nursing board will supply the NMC with their own completed form but a blank copy of the NMCs "verification of good standings" form must also be included despite there being not a single bit of writing on it.
References:
To be completed by two different nurses who are more senior than you and have worked with you for at least 3 months and must be your most recent employer (reference 1) and the other must have worked with you for at least 12 months (reference 2).
Download the forms for "reference 1" and "reference 2".
Tips:
The nurse filling out the form must write "RN" next to their name even though they may have written their role as for example "charge nurse manager" or "charge nurse"
The hospital must have stamped the form with an official stamp in the correct box. If the hospital doesn't have a stamp then they need to write a letter on official letterhead paper listing your application number, name, birth date, stating that they don't have a stamp, signed, dated and attached to the reference form. There needs to be a letter for each reference form if a stamp is not available (ie for reference 1 and reference 2)
If your still currently working for that hospital put your end date as the date you filled out the form with "current" next to it ie 12/2/18 (current)
By your GP:
Cost: GP appointment $18 NZD
Download the "good health" form and get your GP to fill it out
They must have seen you in the last 6 months, hence my appointment fee.
Once again they must have a stamp and if they do not they need to write a letter including your application number, name, birth date, stating that they don't have a stamp, signed, dated and attached to the form.
Other potential forms required:
Unregistered practice
The NMC is very particular about this and states there are two potential scenarios where nurses may have been working without a license
You worked in a country that doesn't require you to register in that country and you are allowed to work with your home countries license eg Middle Eastern countries.
Download the form called "Supporting declaration of registration restrictions" and get the nursing board in question to fill this out.
You started working in a hospital a couple of weeks before you recieved your license.
The NMC will require a letter from your employer stating that they were aware that you didn’t have a license when you first started working and that it won’t cause any problems. The letter needs to include your name, candidate number and date of birth. The letter needs to be printed on letter headed paper of that hospital.
Missing a training area
The NMC requires all 7 of the areas covered in clinical placement: medical, surgical, paediatrics, maternity, mental health, geriatrics and community nursing.
I personally was just given a workbook at my university to complete the "maternity" section of my degree so I had no "clinical" experience which meant that I needed to get one of my charge nurses to fill out the "registration training area reference" form stating that I had looked after pregnant women during my time at Middlemore ED. The other thing to note is that you only have to have looked after a pregnant women once in order to meet the criteria. Interesting right! As if you are "competent" after just one shift.
Posting the forms and the NMC receiving them
Cost: $41.59 NMC track and trace from Auckland, NZ
Make sure you send these via track and track with a signature, that way you know they have arrived safely. This way if anything should go wrong you can ring the NMC and you will have more of a leg to stand on when you can say for example "well on the 25th of June Mary accepted and signed for the documents" .
Once the NMC has received your documents it can take them 2-3 weeks to scan them onto the system and you should start to see them on your online application as "received"
You can send your documents in one go or in bits in pieces but the NMC won't assess your application until every document is there. So my advice is save yourself some money and send it all in one go!
I sent my documents in to the NMC at the start of June and I had a reply back from them mid August just before I left NZ. The NMC states that they will aim to assess the documents and give you a decision between 40-60 calendar days. So make sure you factor in this time before jet setting away from NZ and get your documents completed asap!
Part 4: The NMC Part 2 exam
Cost:
UK Visa including the health surcharge $ 447 + 570 NZD
Two day OSCE course $551 NZD
Part 2 OSCE exam $1910.80 NZD
TOTAL: $3478.80 (£1830.40)
The final and probably the most daunting part of this entire process is the NMC part 2 OSCE exam. Every step of the way you think is hard but this tops them all and the amount of negativity towards it and its well advertised low pass rate certainly doesn't help. The NMC website states that there is a 49% pass rate for your first sitting of the exam and then only an increase of 65% in the second sitting. The statistics don't paint a pretty picture but dont worry I have a brilliant option to combat this that we will speak of below :) This exam can only be sat at one of the two test centers in the UK - Northampton University or at Oxford Brookes University. Northampton is the original testing center and my agency and also Gilbert who ran the course I sat to help me pass this exam (Il give you these details soon!) recommended to sit my exam here and not Oxford. This is mainly because the examiners have been assessing nurses through this exam a lot longer and basically just really know their stuff as to what is a fail and what is a pass. There was also mention of Oxford having some really tough markers that come across mean and unhelpful. My original plan was to sit this exam in the first week I arrived in London before I went travelling for two months to ensure that nursing was fresh in my head. As the time got closer and closer I realised I had so much on my plate already working overtime to get extra travel money, packing up our house in Auckland, continuing to plan our large European adventure and ultimately preparing to leave NZ for at least a couple of years. I spoke to a few nurses that had recently sat the exam and were with the same agency now working in the UK and they recommended that I just dealt with it when I returned from travelling. It ended up being an easy decision and allowed me to procrastinate for a few more months! It did also mean that if I didn't pass first time there could be a long delay to when I could finally start earning an income again which was a slight concern.
My exam date was set for November 24th 2017 and so the count down begun. At the start of November whilst I was in Florence the NMC advisor at Continental Travel Nurse spent a good 1.5 hours on the phone running me through every single step of the OSCE including the critical fail points and the small things candidates in the past have failed on. After finishing the phone call I was clearly still in holiday mode as it was an absolute shock to the system and I felt throughly depressed and overwhelmed at the upcoming challenges I would have to face to do the job I love in a country so similar to my own. The most shocking thing that I was told over the phone was that this wasn't a test of my nursing ability so I could forget everything I knew, it was about how well you could follow a step by step process. On the other hand the most valuable piece of information I was told though was that there was a man called Gilbert who ran courses which helped nurses pass this particular exam. I decided that for the extra money it was absolutely worth it if I could pass the first time around. I booked myself in to do the two day course on the 22nd and 23rd of November and then Lewis and I would take the train to Northampton the night of the 23rd for me to sit my exam on Friday 24th November. Despite having passed the exam with only 2/3 days of training I would highly recommend to do all three. I was the only person who chose to do just the two day and after finishing that second day I felt like I needed the extra day of hands on practice to cement everything into my head and boost my confidence. Gilbert also runs these courses in multiple areas of London but I traveled to Manchester for mine. The details for the course are below:
Costs (as at November 2017):
1 day course: £180
2 day course: £290
3 day course: £375
During the two day course you go over everything in the exam including the three skills: Aseptic non touch technique wound dressing, basic life support and intramuscular injection as well as the APIE (assessment, planning, implementation and evaluation) stages. There is some times for practicing these skills throughout the two days but the main focus of the third day if you decide to stay for this is hands on practice in which you are timed and assessed by Gilbert and you colleagues to help gain confidence and really hone in those skills.
I will give you an overview of all of this myself from the information I gained from the course as well as from my agencg. BUT I can honestly day that proper hands on experience is 100% key to passing this exam.
Skills section
These are the three skills that are currently being tests and on the day you will randomly be given two out of the three. Before you go into each of the skills stations you will be given 5 minutes to read the scenarios on the back of the door as to which setting you are in - home or hospital, what you are supposed to be doing and the time limit. Also note that for every station the examiner will ask you to stand and face the camera to state you full name, that you are happy to undergo the assessment and that you dont know the examiner.
Basic life support
Aseptic non-touch technique wound dressing
IM injection
Basic Life Support
I have to admit that coming from ED this was the ONLY thing in this entire exam that I knew I could pass easily. That doesn't mean there are still small traps that would prevent even me from failing this. The situation your likely to get is that you are a nurse in a hospital that has come to visit another ward when you notice a patient unresponsive on the bed. You know nothing about this patient and you are the sole responder. You are given a time limit of 15 minutes for this station just like all the rest of them but there shouldn't be a chance you will not complete the scenario in time.
I will run through the steps which are taken straight from the UK resuscitation guidelines and are basically identical to what we learn in NZ (aside from the crash call number). You must say everything out-loud. Before you start the scenario the assessor will show you around the room and let you practice using the mannikin for compressions to get the correct height of the bed and the feel for the depth. It is not a clicking dummy but there is a recorder that will measure your depth. ALWAYS go as deep as you can.
D- DANGER - check whether there is anything that would put you - the rescuer at risk. You need to verbally say this "I am assessing for any danger such as.... (ie live electricity, armed offenders, cars etc) and there is none, it is safe to approach"
R- RESPONSE - Check whether the patient is responsive to you by bending down next to them and shouting "Hello can you hear me" in BOTH ears whilst shaking their shoulder/s and then performing a trapezius squeeze to see if they respond to pain. They are a mannikin are therefore won't respond. You need to state " The patient is not responding" and then do three things 1) Shout for help 2) Pull the emergency buzzer behind the bed 3) Ask the assessor to dial 22 22 which is the in hospital emergency number and ask them to get the crash trolley.
A- AIRWAY - Assess the airway in a neutral position. Look into their mouth to see if they are choking on anything. State you would suction if there was any secretions.
B- BREATHING - Perform a head tilt and chin lift. Then you are going to look, listen and feel. You need to put you ear above the mouth and look for any rise and fall of the chest, listen for any breath sounds and also feel any breath on your face for a maximum of 10 seconds. There wont be anything. State " The patient is not breathing, I will commence CPR"
C - CIRCULATION - You now need to commence CPR. It needs to be started in a timely manner but do not rush here. Set up for CPR correctly by stating out-loud how you are locating the position you want to be doing compressions on ie underneath the armpit and across to the center of the chest. Then it is 30 compressions to 2 breaths. It is important that you count out-loud so the assessor knows what you are doing and I recommend counting to 20 and then going back to count to 10 since it can become a bit of a mouthful. Practice this as I found it hard to get my timing right since I usually sing "Ah, Ah, Ah, Ah stayin alive, stayin alive" in my head which is considered the perfect rhythm for CPR. I kid you not, even in a large cardiac arrest resuscitation situation in the ED this is my go to. The aim is to do between 110-120 beats per minute at a depth 5-6cm as per the UK resuscitation guidelines state BUT if you do 123 bpm you will be failed which is why I was so nervous. (An absolute joke really since the patient is already dead and your extra 3 beats per minute is not going to make them more dead!). Once you have completed you 30 compressions you move onto your two breaths. Whilst you are the sole responder the assessor will help you with the bag valve mask by holding it on the face. Make sure that the oxygen is on at the wall. Ensure the patient is in a head tilt chin lift position and then deliver two breaths. You do not need to squeeze the entire bag valve mask. Once you have delivered the two breaths get back on the chest for another round of compressions. They will make you do two rounds before stopping you.
Once you have finished the two rounds they will sit you down and ask you some questions such as:
What are two reasons someone might have a cardiac arrest
Use any two of the 4 H's and T's
Thrombosis, cardiac tamponade, tension pneumothorax, toxins
Hypoxia, hypothermia, hyperkalemia, hypovolemia
How would you know where the center of the chest is to complete compressions?
Underneath the axilla (armpit) and across to the center of the chest
What are two maneuvers to open the airway?
Head tilt and chin lift
Jaw thrust
When would you stop CPR?
When the advanced life support teams arrive
When the patient shows signs of life
When you are physically exhausted and can no longer continue
If there is further danger (ie building collapsing etc)
The patients DNR forms are presented to you
What do you do if the patient show signs of life?
Put the patient into the recovery position, maintain airway, suction if necessary, review ABCD, monitor obs, document and move to a more appropriate place for care
What would you do once the crash team had taken over?
Hand over the situation using ISBAR (Introduce, situation, background, assessment, recommendation), document, hand hygiene
Aseptic Non touch technique wound dressing (ANTT)
In this skills station you will be completing a dressing change on a manikin using the technique outlined in the Royal Marsden textbook. This is rather different to what I know we are taught in nursing school in NZ and I absolutely agonised over the steps in my head trying to memorise them - the use of multiple aprons and having to wipe down your saline solution was just such foreign concepts I had to wrap my head around. I will run through the steps that I was given from my nursing agency of what is required in this station but I cannot stress enough that hands on practice with these things is an absolute necessity. By the way you have a time limit 17 minutes in this station since they realised no one could finish it within 15.
State the environment is safe before you enter
Alcohol gel and introduce yourself to the pateint
Confirm the patients identity by asking for their full name and checking their wrist band
Ask them whether they have any allergies. (note they will have a red wrist band if they do have an allergy)
Explain why you have come to see them today and gain consent for the wound dressing procedure
Check whether they are in any pain and see whether they are due any medication or need to use the bathroom prior to starting
Have a look at the wound so you know what type of dressings you require, the size and ooze on the old dressing before covering up the patient again (ensure curtains are closed and re alcohol gel if you closed them)
You will need to leave the room to get the dressing trolley so give the patient a call bell and explain you will return shortly
Perform full hand hygiene using soap and water
Ask whether the trolley is clean. If the examiner says "Yes within 24 hours" then you just need to clean with alcohol wipes (check the expiry date of these before using). If they say "No" you needs to clean the trolley with soap and water using a side to side motion including cleaning the legs. Then dry it with a clean paper towel.
Once your trolley is clean alcohol gel and then begin gathering your equipment.
Check the expiry date and whether all items are intact (say outloud) and place on the bottom shelf of the trolley.
You will need: Dressing pack, dressing, saline, chlorhexadine wipe, one pain clean gloves, two aprons, sterile gloves pack (or you can use the ones in the dressing pack but these are very hard to open up!) and a container of alcohol gel.
Gel your hands and then take your trolley into the patient making sure your curtains are closed and you have once again cleaned your hands.
Re-confirm your patients identity (since you have left the room technically) and make sure they are happy for you to continue
Put on an apron and open up the sterile dressing pack
Gel your hands before picking up the orange bag within the pack and placing your hand inside which allows you to be "sterile" to move things around on your sterile field. Then turn it inside out and stick it to the side of the trolley - you may not touch this again with your hands. (Also it falls off if you put too much stuff in it)
Another thing they like you to do based on the Royal Marsden is to then use your hand to loosen off the dirty dressing. You need to state your reasoning to the examiner as to why your not going to do this. That reasoning is that if the wound begins bleeding then you do not have your equipment prepared.
Wipe the saline down with the chlorhexaline wipe and allow it to dry for 30 seconds before pouring it into the pot on your sterile field without getting any drops of saline out of the pot. (You can state you would leave it to dry for 30 seconds but because you are pushed for time you can say to the examiner " I presume 30 seconds has passed, may I proceed")
Open the dressing and using sterile technique drop this onto your field
Open your sterile gloves if not using the ones in the wound dressing packet
Gel your hands and put on clean gloves before asking the patient to expose their wound (its a manikin so it wont but always ask the patient to do such things before assisting). Remove the old dressing and assess the open wound for exudate, size, colour, granulating tissue, surrounding skin condition etc outloud to the examiner whilst you are removing your gloves and putting them and the old dressing into the rubbish.
Remove old apron
Gel hands and apply new apron.
Gel hands and put on sterile gloves. Apply the sterile towel around the patients wound.
Clean wound using two wipes to clean and two to dry. Follow a strict clean hand, dirty hand procedure through-out. Pick up gauze 1 with your clean hand and pass it to your dirty hand without touching. Then place 50% of the gauze on the wound and 50% above the wound and complete a single swipe across before discarding it in the bin. Do the exact same with gauze 2 but you are cleaning the bottom 50% of the wound and below the skin. Use the same technique to dry the wound.
Using your "clean hand" pick up the new dressing and apply
Remove sterile towel, gloves and dressing pack and put into orange bag. Then put that bag into a yellow (Hazardous waste) bag before removing apron and alcohol gelling hands.
Lastly ensure your patient is comfortable and verbalise what you would do now that you have finished - ie return and clean trolley, wash hands, complete documentation (updating care plan, nursing notes, sign, date).
*Note: if your break your sterile field at all you need to say so immediately and ask if you can start again. If they say no then ask them if its ok to say what you would have done differently.
IM Injection
The scenario is that you are a community nurse coming to complete a Vitamin B12 injection on a patient at home and you have a time limit of 15 minutes to do so. Whilst it looks as though you are in a hospital setting you have to bring out your inner actress and pretend you are actually about to enter someones home. I will run through the steps with you.
Say "Knock, Knock" and the mannikin will stay in bed but the examiner will speak for them and open the door.
Introduce yourself and confirm the patients identity. Ie "Hello my name is Shannen Kennedy and I am a community nurse looking for Suzie Dee. Are you Suzie?"
Ask whether it is ok to come in and make sure you verbalise that it is safe to enter before you do so.
Explain why you have come to see her " I have come to give you your vitamin B12 injection, have you had this before? Do you know why your having this?"
Perform a full ID check on the patient (ask full name, D.O.B, address and allergies)
Ask the patient where you can get up your equipment and wash you hands (remember your acting as it will actually be all laid out in-front of you!)
Complete a full hand wash using soap and water
Return to the patient and ask where they had the injection last time and whether they have a preference this time.
Assess the injection site on the shoulder and state out loud how you locate the area you will be injecting (ie following the acromion process down 2.5-5cm below)
Speak to the patient about any other medications they might take - ie warfarin or any anticoagulants which mean they might bleed for longer post injection.
Discuss any side effects associated with the medication you will administer and ask if they have any questions before you go prepare the injection
Alcohol gel hands and ask whether the blue tray is clean (if they examiner says no you need to wipe it from side to side with soap and water and then dry)
Whilst the tray is drying (if you cleaned it) gel your hands again and gather the equipment you need, making sure you check all expiry dates and state it out loud.
2 x pairs of gloves, drawing up needle, apron. alcohol wipe for patient skin, wipe for cleaning medication, plaster, syringe, IM needle
When you pick the medication up this is when up you need to complete your 5 rights - check it is the right patient, right drug, right dose, right route, right time. Verbalise the expiry date. Note the "medication" will look like a saline bottle with a label attached.
Gel your hands and put on the gloves and apron.
Clean the medication container using one of the wipes, allow it to dry for 30 seconds and then put it in the tray.
Draw up the medication required, recap using scoop method, show the examiner your draw up medications and then change needle to giving needle.
Remove gloves, gel hands and go to patient
Recheck patient ID and allergy status
Put clean gloves on
Clean skin for at least 30 seconds from side to side and up and down and allow to dry
Begin injecting medication (at a rate of 10 seconds per mil), aspirating and using Z tracking method. Allow to absorb for at least 10 seconds (states this out-loud)
Remove needle and apply pressure whilst you remove your sharps.
Ask if they would like a plaster.
Throw away rubbish and remove gloves and apron. Gel hands.
Straight away go to the prescription and write the batch number (a MUST), sign, date and time.
Write some nursing notes as to where you injected and what it was, any reactions, sign and date.
Check patient is comfortable and advise you will stay with them for 30 minutes to observe for any reactions. Advise them on seeing their GP or calling an ambulance if they require assistance once you have left
Ok so thats the skills section completed, remember you will only have to do two out of the three skills and you wont know until you get into the exam room. The one you feel most uncomfortable with you will probably get so make sure you know that one well. The more nervous you are the more likely you will make a small error - majority of the "critical fails" in the exam would not be such a big real in real life but they are just testing if you are safe to practice. Ok so there is another section of the exam called the APIE (Assessment, planning, implementation and evaluation) stations which you also must complete. Lets start with the Assessment Phase. Note that you will always run through this in order.
APIE
Stage 1: Assessment
In all of these sections coming up one of the most important things you can do is to ALWAYS sign and date it before starting anything else as this is a critical fail element. The usual scenarios that I have been told that they are currently using are these: COPD, Asthma, surgical hernia repair, sub dural haematoma, pneumonia, a vague scenario when someone has come in with abdominal pain and is having investigative surgery - you see then preop, another vague scenario where someone comes in with chest pain and breathlessness. I got sub dural haematoma for mine. Before you get take into the exam room you get given 5 minutes to read over the scenario and the documents provided based on what scenario you get given. You also have a piece of paper with some prompting headings that comes with you through-out all sections of APIE and is for you to make notes and is not marked. This is a good time to scribble some things down for the later sections - as in the evaluation stage you will be expected to find 4-5 points of patient education so make a note of some potential ones now. The main things to note are: name, age, presenting complain/current diagnosis, past medical history, current medications and allergies. The "patient" is an actor and in my case my "patient" was elderly and my actor was around the same age as me so sometimes it is difficult to prompt yourself with normal things you would do at work if you had an elderly patient. You will be taken into the room after you 5 minutes is up and be introduced to your patient and the examiner will also show you around the room. You have 15 minutes to complete this station but don't look at the clock until you get to writing down your completed NEWS score it will only freak you out.
The first thing to do is state out loud the room is safe to enter
Complete hand hygiene at the same time as you introduce your self to the patient
Confirm their identity verbally and also with their wrist band
Check for any allergies
Build up a rapport with the patient and speak to them about why they are in hospital etc
If they say they are in pain investigate this using whatever framework you would normally use, dont ignore it.
Complete a set of vital signs - you will either have to complete the NEWS (national early warning score) or the Glasglow coma scale (if you get subdural haematoma), NOT both and depending on your scenario you will be given this. But note that their GCS is different to NZ and also includes basic vital signs. Also before you use the blood pressure machine you need to check whether it has been serviced and calibrated as well as cleaned. (I know, eye roll). If the examiner states it not clean (unlikely) then you will need to wipe it down. They may also state whilst they are showing you around the room that the machine is serviced, cleaned and calibrated to save you asking.
Blood pressure, HR (manual radial for 1 full minute - but make a note of what it is on the pulse ox just incase), Resp rate (For 1 full minute seperate to taking HR), temperature, SPO2, Pain score, urine output, GCS
The order to do it is this
Attach the BP machine but don't inflate it yet - feel for the brachial pulse before attaching and make sure the cuff is 2cm above the pulse
Check capillary refill of the finger before applying the pulse oximeter
Check tenperature
Start the BP machine and whilst this is pumping up get the clipboard and document all the observations you already have
Once BP is completed but you hand on the patients radial and put it across their stomach. Count for 1 minute for heart rate and another seperate minute for resp rate - verbalise you have completed both to the examiner. I can assure you it will be the longest 2 minutes of your life and your hands will be sweaty!
Ask them whether they have passed urine, have any pain and if you noticed they are diabetic ask the examiner what their blood sugar is
Complete the NEWS score documentation including the total score, monitoring frequency and escalation. Verbalise this
IF you have been given the GCS then you will need to complete the basic vitals, plus also ask them the usual questions for GCS
Check eyes opening, check orientation, and check limb movement
Check pupils for size and reaction (there will be a pen torch for you)
Check limb strength - just get them to lift their arms up and hold them, Then get them to grasp you hands and push/pull you away. For legs get them to resist you pushing up and the pushing down.
Another thing to note is that there are certain "traps" put into the room and it is hard to know how many you will get, they are:
Lighter and cigarettes
tell the patient smoking is not allowed in hospital
The lighter is a fire hazard
Give brief smoking cessation advice
Remove both and either give to examiner of put in a draw beside the patient
Water bottle and patient is NBM
Explain what NBM is and remove water (into draw or to examiner)
Lollies and patient is diabetic/NBM
Briefly mention the impact of sugar and diabetes as you can assume they have been spoken to about their diet
No need to remove these
Inhaler
Check expiry date and state you will get this prescribed by the doctor
Walking stick
Ask if they would like this to be brought closer
Note it could be lying on the floor or over in the corner of the room
Glasses
Ask if the patient can see ok or if they need their glasses
Hearing aid
Ask if they can hear ok or if they need their hearing aid in
Sputum cup
If the patient is coughing a lot ask them to spit in the cup and it will be sent to get analysed
Note: no one has failed missing this trap but you should address it
Address these ideally after you have taken the observations but sometimes you may be prompted to discuss them at the start since the first thing a patient might say as you enter the room is "can I go for a smoke" address that trap then and there.
The next section of "Assessment" is the ADLs and ideally you should cover the "Traps" within this section as they will provide you prompts. You will be given a form that outlines the heading they want you to cover - it wont be all of these below that you will have to speak to them about. Think about the sorts of questions you might ask for each section.
Maintaining a safe environment
any confusion, difficulty mobilising, falls risk
Communication
hearing aid, glasses, translator needed
Breathing
smoking, inhaler, sputum cup
Eating and drinking
NBM, diabetes, fluid balance, fluid chart
Elimination
bowels opened/constipated
Washing and dressing
?independent, any home help
Controlling temperature
?fever
Mobilisation
walking stick/frame
Working/playing
retires or still working
Expressing sexuality
?stoma
Sleeping
do you take any medications to help?
Death and dying
Don't bring this up unless they are palliative.
Another thing to note is that the patient may bring up some things they are worried about and you need to address each of these, alleviate their fears and look for two problems you could use in your care plan. Some examples are
The patient is struggling to breath
The patient is concerned about their wife at home that they care for
The patient is in hospital for a hernia repair and is a landscape artist and wants to know when she can go back to work
The patient might be confused or aggressive
The patient might be anxious about the drugs they will be taking whilst in hospital.
Stage 2: Planning
This is a writing station with no actors or manikins. You will be given 15 minutes to write a care plan for your patient and you need to think of what the TWO most immediate medical problems for your patient are. You are given space for three but I can 100% tell you that you wont have time to do three and two is all thats required. The most important thing for you to do first is complete the patients name section and sign. Critical fail points that if your stress at the end you will forget about. For each care plan you will need to identify the following:
Nursing problem - written in full sentences
Aims of care
This needs to be "SMART" - specific, measurable, achievable, realistic and time orientated
Specific to nursing problem and vital signs
Reevaluation date
ie "Mr Smiths care plan reviewed every shift from (todays date) unless his condition changes
Care by nurse
Everything your going to do as a nurse ie Observations, GCS, analgesia/medications, education, falls risk and pressure area documentation
Care by patient
Everything the patient will do
ie: Using deep breathing and coughing techniques, alerting nurse when he requires analgesia, able to use the call bell, consenting to treatment etc
In my exam I got subdural haematoma for my patients presenting complaint and the two nursing problems that I used was "Headache secondary to subdural haematoma" and "falls risk secondary to impaired mobility and confusion". I suggest you just make a note of some of the points you might want to talk about in your care plan so you have a rough idea when you get into the exam. Also time yourself to complete this since I can assure you that 15 minutes is not a long time to scribble two full care plans down. The worst thing about it is in clinical practice this is not a time sensitive thing - you will never be timed to complete a set of notes on a patient. But we can't change this so just make sure you get it all down! Some more tips
If you make a mistake, cross it out, write "error" and initial next to it
Always make sure you have signed and dated each page and the patients details are present
Everything you write about must be able to be completed within 24 hours. For example if you get "asthma" make sure one of your nursing problems is NOT smoking cessation. Whilst this is very important it is not one of your immediate concerns.
Write neat and clear
Stage 3: Implementation
In this station you are expected to implement patient care by administering ORAL medications to a patient (manikin). The patient is the same throughout the APIE stations so you will have already met this patient. Once again you have a 15 minute time limit and before the timer is started the examiner will show you around the room which includes the medication supply. Note also that the time is not the time that it is on your fob watch but is the time on the front of the medication prescription. This is something I messed up until I realised I had no medications to give at the time I thought it was! Close call. This is the steps below you need to take.
Verbally state the environment is safe to enter
Alcohol gel your hands as you approach the patient and check their identity and allergy status
Explain why you have come to see them, check they are pain free and comfortable
They might state they are short of breath - ask the assessor for their O2 sats, reposition them.
There might also be an oxygen mask sitting behind the bed BUT this must be prescribed so you cant automatically put this back on them
Begin going through the drug chart first before dispensing anything. Remember the time on the front is the time your using: either 1200 or 1700hrs.
NOTE: The patient in the exam usually has an allergy. If you notice that they have amoxicillin prescribed and they are allergic to penicillin then you MUST state this out-loud to the examiner, state you will inform the nurse in charge and the doctor, state you will fill out an incident report AND also make sure you put a code next to the drug as soon as you notice this (I think the code is 6 but make sure that is the correct one). This is the only time you can write on the drug chart as you have to sign and time the medications after they have been given (If your anything like me I often write the dose into out NZ drug charts and then sign and write a time after I have given it so that I remember what I have out - DON'T)
There are 5 things you need to do on the first page.
Check the patients details
Check the allergies
Any dietary requirements?
Check the codes (these are what you write down if the patient refuses meds, are not present on the ward etc)
Check the height and weight
Second page- contains once only/stat meds, O2 therapy and PRN drugs
Read everything out-loud and when you reach pain relief/anti nausea ask the patient if they are still having issues with this
If you notice any IV drugs been given - assess the cannula site
O2 therapy under "therapy instructions" will either be:
discontinued
Consider stopping O2 when target saturations met (you will be given the target saturations also) - therefore you may need to ask the examiner what the patients current O2 sats are
Continue O2
Third and fourth page - contains regular medications
There are 6 points on this page you need to verbalise for each of the regular medications so you know what medications are due
Drug name
Drug dose
Start date
Finish date
Prescriber signature and bleep # present
Time due
Fifth page - contains IV fluids
Read out the fluids and if the patient has any running check what they are and whether they are running through at the rate they are supposed to (roughly)
This will also prompt you to look at the fluid balance chart provided. Just look for any glaringly obvious mistakes. You dont need to chart anything but just glance at it and make reference to it.
Ok now that you have been though the chart there should be at least a couple of medications you need to dispense to the patient.
Make sure that you are not giving anything contraindicated with their presenting complain ie warfarin and they have a brain bleed, paracetamol that was given 2 hours ago, amoxicillin they are allergic too etc. Always stick to giving paracetamol every 6 hours in this exam.
Get each medication out one at a time and put them in seperate containers.
If you are dispensing medications such as antihypertensives or digoxin ask the assessor what the current BP or HR is.
Go to the patient and state what medications you are giving them, ask if they know what they are for, and check they are happy to take them.
Because it is a manikin you pretend that you have given them to the patient and say to the assessor "Can I assume the patient has taken their medications?"
Straight away sign your drug chart and say you would update your nursing notes, check your patient is comfortable, call bell within reach, gel your hands and leave.
If you run out of time verbalise to the examiner what you would do and say that you wouldn’t usually timed for this.
NOTE: The examiner will ask you some questions about the drugs/general medication safety questions like common side effects, why do you give IV medication slowly etc. They will always have a BNF available to use (thats the same as our NOIDs/MIMs in NZ) and if you don't know the common side effects look them up. Equally if you do know the commons side effects say them to the examiner but also state that if you weren't sure you would use the BNF.
Commons drugs you should know:
Omeprazole
Lactulose
Digoxin (HR must be >60bpm to administer)
Frusemide
Bisoprolol
Amlodipine
Warfarin
Aspirin
Clopidogrel
Heparin/enoxaparin
Simvastatin
Salbutamol
Ipratropium
Beclometasone dipropionate
Diazepam
Amitriptyline
Cyclizine
Domperidone
Prochlorperazine
Ondansetron
Paracetamol
Co-codamol
Amoxicillin/Co-Amox
Gentamicin
Trimethaprim
Ciprofloxacin (not penicillin)
Morphine/Oxycodone
Stage 4: Evaluation
This section is basically like you handing over to another nurse on a different ward (although with waaaay too much information that if you were to read this out to the new nurse it would take half a shift!). Once again you will be taken to the room to write and you will be given a blue pen and all black pens will be removed from you. This is because you are also given all your documentation from the previous stations in order to complete you summary/transfer of care letter and prevents you from correcting/adding anything. You will be given 15 minutes to complete this. The way I have been told to fill this out below is considered the fastest as you copy down everything already know from previous parts of the exam before getting into anything else you need to think about.
First complete the patients details and sign and date each page (3 pages)
State their main reason for admission (the medical issue they have) ie "Subdural haematoma"
Skip forwards to page two under "medications given" heading fill this out
NOTE: Medication includes IV fluids and also oxygen that have been given
This is also ALL medications from the time they were admitted and not just the drugs you administered
Then go back to the front page and complete the nursing care plan section by copying and pasting what you wrote earlier.
The title "Nursing approaches/interventions...potential nursing care needs/problems" is the same as CARE BY NURSE
MUST include NEWS score/GCS
The heading "Any drugs omitted with reasons" writing the reasons out in full and not codes like you would in the drug chart
Fill out Allergies
Make up 4-5 points under the heading "identified/potential areas for patient education" and this is where it is important that you note down anything in stage 1 assessment when you get to read through the patients full notes before entering into the station. Thi
Smoking cessation
Deep breathing and coughing
Diabetes education
Fluid restriction
Post op care - deep breathing, mobilisation, signs of infection
Diet and nutrition
Then under "Actual or potential problems that may risk/complicate the patients discharge/recover" write 4-5 points here such as
Risk of hospital acquired infection
Non compliance of treatment
Falls risk
Pressure areas
Uncontrollable pain
Deterioration of condition
Take a deep breath at this stage as you are DONE!! If your anything like me I absolutely fretted over everything convincing myself that I had failed. I even emailed my tutor from the past few days asking him questions I should have asked before the test but forgot. On my way out of the test center I asked the girl at the reception how long I would have to wait until I can resit the exam partially. You either get a full fail which is when you have to resit everything or a partial fail where you may have to only repeat the skills section or APIE depending on what you have messed up. The girl told me that I would have to wait until January next year if I was going to partially re-sit as many many people have to do this. However, if you need a full resit there were spaces for that straight away. Just note you are allowed two attempts at the exam and between your first and second attempt you must allow 28 days. Once your done with your exam that day force yourself to go out and celebrate no matter how you feel. A weight has partially been lifted off your shoulders!
The next morning we took the train back to London and on Monday the following week when I was in the middle of my mandatory training class I checked my emails. I almost cried tears of joy and relief as I saw the email title below. It had almost been a year since I sat my first exam December 3rd 2016 to begin this entire registration process - what a mission it has been and I can totally understand why so many skilled Kiwi nurses don't bother! But it will always look good to have it on your CV.
I started my first UK job December 4th 2017 with Continental Travel Nurse at St Thomas's Hospital A&E which is in the Guys & St Thomas's NHS Trust. UK nursing was a bit of a shock to the system as I felt all the autonomy I had at Middlemore was completely stripped from me. The large list of medications I could prescribe there was something I couldn't do here and instead if nurses being relatively proactive it felt a lot like a "just wait for a Dr to order that" kind of attitude. No one wore stethoscopes and I discovered that its not expected of nurses here to be able to complete a full respiratory, cardiac or even a abdominal assessment. I had to get signed off for everything again from medication administration, IV lines/phlebotomy and catheterisation. I had only three days orientation to try and find my way around the new environment. My roster was a lot more horrific than home (except in the last 6 months when I was working stupid amounts of overtime) and the nurses are expected to be completely full time with one week of 3x 12 hour shifts and another week of 4 x 12 hour shifts. That would be considered 4 hours overtime at home! It took me a good few months to settle in and there were a lot of times I just wanted to sit in the corner and cry. I regretted having spent so much time and money completing my nursing registration over here but kept reminding myself that it will always look good on my CV....despite the feeling of just being expected to make cups of tea all day! I got used to actually calling the charge nurses "sister" and having a "matron" which were always just funny words from old movies/stories for me. I even made the mistake of calling for "Martin the sister to come to Majors" in which everyone laughed hysterically at men as males weren't called sister but still infact called charge nurses. A vital piece of information no one had bothered to share with me. All the gay male charge nurses we have just love being called sister anyways so they weren't too offended by my muck up. There is also different band of nurses and it is waaay more hierarchal than at home as these nurses wear different uniforms. I was considered a band 5 staff nurse which is the bottom of the rung. The other thing thats was something that took a lot of time getting used to is that you are expected to document and check for pressure ares down in ED. Now this is something we 100% don't do at home in ED and there is so many other more life threatening or urgent treatments that you need before we would even have the chance to consider whats happening on your backside. Unless of course thats what you have come in for of course. Here I have been asked about the skin of patients who are completely independent and in their 30's. I have been made multiple times to come to the bedside with the nurse that I am handing over to in order to check the skin of these patients as my answer of "they are young and completely mobile?" did not satisfy them. If you do happen to have the unluckiness of discovering some broken skin on someone heels or backside you then have to complete a lengthy incident report which basically covers the hospitals arse if the patient or family try and suggest that the hospital actually caused these sores whilst they were visiting. May I just add that this is on top of being expected to save live here guys :P! I spent three months at St Thomas's before I moved agencies as Continental was being threatened of closure and I joined Firstpoint Heathcare. The rates are basically double what I would get as a permanent staff member at a hospital which i why this wasn't work it for me. As a Emergency Nurse with 4 years experience and a post grad certificate in advanced nursing with a current Advanced Cardiac Life Support certificate I would earn the same amount as a new graduate nurse in New Zealand does. Absolute daylight robbery. Everyone said that the grass was not greener on the other side when it came to these other major trauma center hospitals that I was keen to get to. Man were they right. They are so inundated by trauma that every other presentation is almost disregarded. Thats how it should be though since I wouldn't want someone with a cold for 2 days to get seen before someone who had a fall of a 2 story building with potential life threatening injuries.
Ok so in terms of over all cost of getting my UK nursing registration I have calculated it below. This is the first time I have given myself a figure as it was too painful previously to think about how much I spent to prove that I could do what I could already do in another country.
IELTS: $395 NZD (£201)
Part 1 exam: $522 NZD (£275)
Paperwork and documents required: $562.86 NZD (£296)
Part 2 exam and visa & course $3478.80 (£1771)
Mandatory training £70.80 ($139 nzd)
HIV bloods £60 ($117 nzd)
Admission onto our register £153 ($305.60)
TOTAL: $5670 NZD/ £2888
The NMC has listed on their website the estimated cost of getting your UK registration to be £1415 ($2777 NZD) and as you can see it is over double what they estimated the cost to be. Food for thought.
Below is the contact details for Gilbert for the training courses he runs. Highly recommend it, there is nothing better than getting hand son experience. Its worth the money.
All the best fellow nurses on your journey through the minefield of becoming a UK Registered Nurse and please contact me if you have any questions :D