Caring for a patient in a professional manner is fundamental to effective nursing care.
The role of the nurse has developed from its originals and continues to evolve to enable the delivery of evidence-based care within a wide range of settings.
The four fields of nursing within the UK enable nurses to develop specialized skills to ensure patients receive the best care possible.
Recent changes in nurse education have enabled nurses to continue to develop the skills specific to their field of nursing, but also to develop competency in a range of generic skills.
There are similarities and differences in nursing across the globe.
Good nurses share a range of professional attributes, including the 6Cs.
Listening to the patient is a fundamental part of good nursing care.
Throughout your nursing course you are expected to act as an independent and professional learner.
The knowledge and skills you gain will reflect all of the fields of nursing, not just your chosen one.
Confidentiality is fundamentally important to all aspects of your learning, as well as patient care.
During your nursing course there is a wide range of sources of support which you can access.
Being a nursing student is challenging, but also hugely rewarding.
Managing your time effectively is crucial to successfully completing your course.
You must, at all times, speak out if you witness what you think is bad care.
Only evidence can tell us what is the most effective nursing care for each individual patient.
There may not be theoretical or research evidence available to inform all of the decisions we need to make as nurses, either because the questions are not researchable or because they have not yet been researched.
Using a range of evidence (observation, reflection, patient experience, theory/ research) gives us the highest probability that we will deliver the best care for patients.
As we rely on evidence to deliver best practice, it is critical for that evidence to be ‘trustworthy’.
Research is a systematic way of finding answers to questions. It is considered to provide the most reliable source of information to answer the clinical questions we generate.
Reflection helps us to analyse our own observations or actions in a systematic and objective manner in order to produce evidence to underpin future practice.
Understanding the value of different genres of literature and how they can inform academic writing will help you to select sources of information that are appropriate to the questions you seek to answer.
Using databases of journal literature that can inform your academic work and clinical practice is more systematic and trustworthy than using the internet directly to source information.
A good piece of academic work will provide enough information about sources of theoretical or research evidence for the reader of the work to retrieve those sources and check them against what has been submitted.
Academic writing is not just about demonstrating understanding; it must also demonstrate an ability to reflect on, and apply theory to, practice.
Owning your arguments and incorporating personal reflection on how your understanding of theory can inform your practice demonstrate that you understand the important issues at stake, are familiar with the evidence relating to them and can use this knowledge to inform your decision-making in practice.
A strong piece of written work starts by clearly setting out its intentions and then takes the reader on a ‘journey’ through the work in a logical and coherent way.
A useful acronym to bear in mind when writing paragraphs relating to practice, as in a case study, is PEAN: Point – Evidence – Apply – Nursing.
Familiarize yourself with the criteria against which your work will be assessed, and with the marking schemes that will be used for grading purposes.
Ensure you understand the sources of support available to you and use these to help you during your course.
All nurses encounter a range of ethical issues in their day-to-day practice.
It is important that we develop ethical sensitivity so that we recognize ethical issues.
Ethics requires us to provide a reasoned, sound rationale for our professional actions.
Commonly held values inform actions at individual, professional, community and societal levels.
Different ethical theories and principles encourage us to examine situations in different ways.
At times we can be faced with decisions that seem to require us to do two incompatible or undesirable things: these are ethical dilemmas.
Various frameworks are available to assist nurses with ethical decision-making.
Healthcare law has developed to protect the interests of patients, and nurses have a duty to ensure that they abide by its principles.
For a claimant to win an action on negligence, three elements must be satisfied: that a duty of care was owed to the patient, that there has been a breach in the standard of care and that the breach has caused reasonably foreseeable harm.
The Mental Health Act 1983 can be invoked to impose treatment upon patients against their will, but this treatment can only be for the mental illness from which the patient suffers.
There is a presumption that adults have the capacity to make decisions, but this can be overturned if the patient fails the test of competence outlined in the Mental Capacity Act 2005.
Treatment can be given to an incompetent patient without their consent, provided that it can be shown to be in his or her best interests.
The maintenance of patient confidentiality is a sacrosanct principle within healthcare, and those who breach it may face legal, contractual and professional penalties.
Both students and registered nurses can be held accountable for their actions, but whom they are accountable to differs.
Students who accept a delegated activity are then responsible for their actions.
As a nursing student you are part of a profession where your behaviour both at work and in your personal life will be judged against the NMC Code.
The public need to have confidence and trust in individual nurses and nursing as a profession if effective therapeutic relationships are to be developed.
It is the role of the NMC to protect the public, and they set clear guidance for students and HEIs on areas that may cause concern about a student’s fitness to practise.
Students whose character or health raise concerns regarding their fitness to practise may be referred to a fitness to practise panel, which could lead to their removal from the course.
Being a nursing student is both a challenging and a rewarding experience. To adjust and cope with the requirements of this, you will benefit from adopting proactive strategies to enhance your personal and professional resilience.
Professional resilience is the ability to ‘bounce back’ in stressful situations. It is an important attribute for contemporary healthcare professionals.
Nurses are expected to proactively promote the health of others. It is important that you fully consider the implications of your health behaviours as a role model.
Maintaining professional wellbeing can be enhanced by a good understanding of psychological concepts such as coping, adjustment and self-awareness.
National policy literature such as the Foresight Report (2008) and NICE (2009) guidance offers helpful evidence-based advice for maintaining wellbeing.
NHS organizations have a responsibility to promote the health of their employees.
Nurses have a professional requirement to maintain up-to-date knowledge and be of ‘good health’.
The NHS is currently undergoing the most significant change to its structures and systems since its inception.
The most significant driver for change is the focus on improving the quality of the care that health professionals provide to patients and carers.
Nurses are in the best position to identify the need for and to drive forward change to improve the quality of care and experiences of the people for whom they care in their daily working lives.
Considering the NHS Change Management Model (NHS, 2012) as an extension of the nursing, midwifery and caregivers strategy (DH and NHS Commissioning Board, 2012), the 6Cs of nursing (Hollis, 2013) and the principles of ‘Energising for excellence’ (NHS England, 2014) provides nursing students with a framework that can help them to identify the need for change and implement changes that improve patient care.
The focus on quality in healthcare delivery arose in the 1990s after a number of serious failings in healthcare.
High-quality healthcare is safe, effective and provides a positive patient experience.
Each country in the UK has different regulators to monitor quality in health and social care organizations.
Clinical governance is a framework designed to ensure delivery of high-quality healthcare that is safe and makes clear the accountability of staff involved at all levels.
The seven pillars of clinical governance are: clinical audit; clinical effectiveness; patient and public involvement; risk management; staffing and staff management; education; training; and continuing professional development and use of information.
Students have a responsibility in relation to the delivery of quality in healthcare by ensuring that they always work within their level of competence, actively engage in learning and always follow policies and procedures and ask when unsure.
Where students have concerns about the quality of care being delivered, they should discuss these with their mentor or someone from the university.
In order to ensure that the care provided is ‘good’, benchmarks for good practice are applied.
Questioning nursing practice is essential in order to enable the body of knowledge to grow and to be used to provide care of the best quality.
NMC standards and guidelines are designed to prepare safe and effective nurses capable of providing evidence-based care.
As a nursing student you must work within the limitations of your competence and never undertake any aspect of care that you are not qualified to carry out.
Decisions regarding whether care is good or not must encompass the opinions of everyone involved in this process.
In order to demonstrate effective care, a holistic, integrated, person-centred approach must be applied.
The importance of care and compassion in nursing must never be forgotten and you must demonstrate attributes such as authenticity, congruence, respect and warmth at all times.
Delivering the best nursing care is a priority for nursing as a profession. In order to be able to give the best care, we must recognize what best care is, and what this means to different people.
Considering the theoretical aspects of the core concepts of nursing helps you to appreciate and communicate the care you are giving.
Nursing models address care and aid communication about what your role as a nurse is, how the patient may be viewed, what the context or environment for nursing might contribute and what the intended outcome of care might look like.
Models and processes of nursing are simply part of the toolbox which enables you to ensure effective care as a nurse.
Models and processes of nursing can be used within each field of nursing and will be useful to you in delivering patient care.
There are four core concepts found in the meta-paradigm, or worldview, of nursing theory, and these are linked together in a model in order to enable you to provide holistic care.
Nursing theories are developed while they are being used and intertwined with interprofessional theories to enrich the effectiveness of care delivery.
Promoting compassion, care and dignity is fundamentally important in every aspect of nursing care.
A number of serious failings of care can be identified within the history of nursing since the 1960s.
Numerous nursing theories and models are based upon person-centred care, creating an environment where the uniqueness of each individual is recognized. While the terms ‘person-centred care’ and ‘patient-centred care’ are frequently used interchangeably, it should be remembered that person-centred care was devised as an approach that moved care provision away from a position in which personhood did not factor.
We all hold values and beliefs which, because they shape the ways in which we think, feel and behave, can impact upon the care we deliver.
The more aware we are of our values and beliefs, the more likely it becomes that the values enhancing effective relationships with patients will be strengthened.
Spirituality is both an integral aspect of daily life and a necessary consideration when delivering holistic nursing care. If it is considered as an everyday ritual, which provides security and structure, it can be incorporated into the areas of care that we already consider within the nursing process.
As a nurse, your primary function is to protect those in your care. Care which does not uphold and promote fundamental nursing values is never acceptable.
A range of terms is used to refer to people who use health and social care services.
Some people have preferences regarding the terms that are used to refer to their relationship with the services.
The support needs of individuals may be met by family/informal carers and people who are paid to provide care/support.
Those who are paid to provide support may have an in-depth understanding of the needs of individuals, but they may not have healthcare training.
Providing care can have an impact on family/ informal carers and it is important that the needs of such carers are recognized and met.
Such carers may not, however, view themselves as ‘carers’.
In planning and delivering nursing care it is essential that we work in partnership with individual patients, their family and their carers to ensure that care is person-centred.
Different fields of nursing adopt differing approaches to care to enable nurses to best meet the patient need.
APIE is a generic process in all fields of nursing, regardless of the approach to care.
The process of APIE is cyclical and ongoing.
Assessment is fundamental to care; holistic assessment is essential for effective care to be delivered.
Efficient planning of care is an important aspect of the process; SMART planning criteria allow patient needs to be translated into achievable goals.
The implementation of evidence-based care is critical to resolve patient problems, and is a professional requirement of nursing.
In evaluation you assess responses to care, appraising whether goals have been met and problems resolved.
The ability to communicate effectively is the most important skill a nurse can possess.
Communication plays a role in patient safety and satisfaction, facilitates therapeutic relationships, enables nurses to collect important data regarding patients and facilitates nursing interventions and their evaluation.
Observing non-verbal cues is important, especially with children and patients who are unable to communicate verbally or may not have the vocabulary to accurately communicate their thoughts and feelings.
The use of journals, reflection on practice or clinical supervision is a valuable strategy for developing insight into your values and beliefs, as well as your strengths and areas for development.
The UK is becoming increasingly multi-cultural; this requires nurses to not only develop strategies for communicating with those who do not speak the national language, but also to understand how different cultural beliefs can impact on a person’s understanding of healthcare and treatment.
There are many barriers to communication in nursing which nurses need to identify and learn how to overcome.
Various professional and personal skills, knowledge and attitudes are needed to handle challenging situations, including communication and interpersonal skills and the skills needed to de-escalate potentially aggressive situations.
Being able to maintain professionalism during times of conflict is a reflection of the professional role of the nurse.
Nurses need to have good professional boundaries during challenging situations.
At all times, no matter the situation, patients must be treated with respect.
It is important not only to give support as a nurse, but also to recognize the need to receive it.
Risk cannot be avoided and is present in everything we do.
As nurses, we will work with a variety of patients, some of whom are more vulnerable than others; therefore we must develop skills for assessing and managing risk.
Decision-making skills and professional judgement are fundamentally important in managing risk.
The value of reporting and learning from incidents that occur in everyday practice must not be underestimated.
It is not possible to prevent risk, but it is possible to prevent error. By focusing upon the human factors that cause error we stand a far better chance of ensuring patients remain safe.
It is important to maintain accurate patient records which provide a contemporaneous account of a patient’s journey in order to improve and monitor care.
The Nursing and Midwifery Council (NMC) states that record-keeping is an integral part of nursing practice and is essential to the provision of safe and effective care.
Nurses have to complete a number of different records depending on the nature of the patient and the service provided.
The principle is that if care given is not recorded, it is presumed not to have occurred.
All parties involved in providing care should be involved in record-keeping – patients, carers, nurses and other health professionals.
Patient records must be kept safe and stored appropriately to maintain confidentiality.
Poor record-keeping can result in you being held accountable to your professional body, particularly if harm comes to a patient.
Within healthcare settings there is now a move towards electronic record-keeping.
Effective decision-making is an important aspect of the provision of high-quality nursing care.
Nurses in all fields and all settings make a large number of decisions.
Decision-making involves the integration of theory and practice.
A number of strategies can be applied to assist in developing the core skills required to make decisions that are holistic and patient-focused.
Engagement of the patient and their family in the decision-making process is essential.
Health promotion involves enabling people to gain health in spite of illness or inequalities and is an essential part of the nurse’s role.
Health is an attainable condition but is never complete.
International principles are used to design health promotion projects and interventions.
A range of theoretical models can be used to help structure health promotion plans and practice.
Health promotion is an aspect of public health.
Health education is an important component of health promotion, but health promotion involves more than just health education alone.
Behaviour change is an important goal in promoting health.
Health promotion is applicable in all settings and in all fields of nursing.
Effective safeguarding requires a proactive approach to nursing practice, which is more than just simply protecting vulnerable people from harm.
The six key principles of safeguarding are empowerment, partnership, protection, prevention, proportionality and accountability.
There are both similarities and differences in children’s and adults’ safeguarding. Essentially, adults are presumed to have mental capacity while most children are not.
It is important that you understand the safeguarding policy and legislation that apply in the country in which you are practising.
We are all potentially vulnerable depending on personal circumstances, environmental risks and our own resilience.
Research by vulnerable adults informs us that we must listen to them, believe what they say and ultimately do something about their concerns.
The Winterbourne View Serious Case Review (DH, 2013) and the Francis Report (2013), a public inquiry into the failings of Mid Staffordshire NHS foundation trust, highlighted widespread institutional abuse of patients.
Questioning and reflective practice should always be encouraged.
Seek help immediately if someone for whom you are providing care has suffered harm for any reason.
The development of patient participation and responsibility has strengthened the focus on education.
Education can improve patient safety, adherence to interventions and satisfaction and strengthen self-management.
Patient activation can promote behaviour change.
If recommending web-based sources, professionals must seek to ensure that patients are directed to legitimate sites where reliable and accurate information is provided.
Involve patients’ carers and families where appropriate.
When evaluating educational activity, consider outcome measures.
Preventing infection relies on an awareness and knowledge of all the factors that contribute to the complexity of decision-making regarding when to perform hand hygiene or wear gloves.
Ensure that you are always able to identify both poor practice and positive role models for practice.
Always reflect upon incidents relating to poor infection prevention and control to enable you to improve your practice. It is important to know where to access infection prevention and control-related information and have the confidence to seek support from specialists.
Ensure you develop and maintain an awareness of research findings, so the care you provide to patients has a sound evidence base.
While the management of waste may not strike you as a nursing responsibility, the production of waste is an unavoidable consequence of our role and the care tasks undertaken.
If you follow the principles it is possible to manage healthcare waste safely and effectively in all settings.
Detecting early deterioration in a patient’s physiological condition is an essential skill for all nurses.
Effective communication skills are of fundamental importance while taking clinical measurements.
Attention to detail when performing clinical measurements is vital to ensure accurate results.
An understanding of the relationship between anatomy and physiology and clinical measurements is key to monitoring a patient’s wellbeing.
Clinical measurements can be recorded in all fields of nursing and your skills need to be adapted to the context.
Appropriate responses to the findings of clinical measurements are central to ensuring a patient receives effective care.
Performing clinical measurements requires a combination of skill and knowledge that can be life-saving for a patient.
Undertaking an effective pain assessment is key to managing a patient’s pain.
For a pain assessment to be accurate you need to use your communication skills effectively.
Never ignore a patient who is in pain – even if you find it uncomfortable to deal with or do not have the knowledge or experience to do so, find someone who does.
Never tell a patient that pain is to be expected or normal, change the subject or jolly them along. It is essential that you identify the physical, psychological and social impacts of pain in order to reduce the stress and impact of the pain itself.
Nurses need to have a good understanding of pain management strategies in order to deliver effective care to patients.
There are numerous ways in which pain can be managed – you need to constantly evaluate a patient’s pain and, if the management is not effective, use another approach.
Providing effective analgesia will enable the patient to be as independent as possible in their activities of daily living.
Pain management is crucial in maintaining the dignity, independence and safety of all patients.
An aseptic technique protects the patient by preventing contamination of vulnerable body sites or contamination of specimens.
Considerable confusion exists between the use of clean and aseptic techniques.
It is important to understand the principles of asepsis, so you can apply them appropriately to the care required by patients.
Specimens should only be sent when clinically indicated.
Specimen or laboratory forms must be fully completed, with all relevant clinical information included.
Storage, transport and time taken for specimens to reach the laboratory can impact on results.
Pain management is a priority in caring for a patient’s wound.
Any decision about wound care needs to consider all of the patient’s needs, not just their wound.
Recognizing the type of tissue in the wound, the stage of wound healing and the factors that may adversely affect healing are fundamentally important when setting realistic and achievable treatment objectives.
All wound-care-related treatment should, where possible, be discussed with the patient.
If a patient is malnourished and/or dehydrated then this must be addressed or it will negatively impact on healing.
Any patient at risk of pressure damage has to be nursed using pressure redistributing devices and manual handling must be carefully carried out to avoid harming their skin.
Always consult relevant guidance and protocols to ensure patients benefit from a consistent approach and evidence-based decisions.
The safe handling of people is a complex procedure.
A risk assessment must be undertaken for all people who require assistance with their mobility.
You need to understand how your anatomical structures relate to movement and back posture in order to ensure you do not injure yourself.
Always consider the principles of movement and posture when assisting people to move.
Utilize the principles of movement to work around beds, trolleys and couches in hospital and community settings.
Moving patients is not just a physical activity – ensure you listen to the views of the patient and the team involved in the move.
Health professionals currently follow Smith (2011) The Guide to the Handling of People: A Systems Approach, to ensure they plan effective mobility care.
The priorities of first aid are to preserve life, limit worsening of the condition and promote recovery.
The Drs ABCDE approach is helpful in all emergency situations.
To achieve the priorities of first aid pay attention to ensuring a clear airway and effective breathing and circulation.
Early good-quality cardiopulmonary resuscitation and defibrillation offer the best chance of survival for a patient who suffers a cardiac arrest.
External bleeding can often be controlled by applying direct pressure to a wound. If there are objects in the wound, indirect pressure should be applied.
Never forget to call for help as soon as you realize you might need it.
Medicine administration is a holistic and integral patient-caring activity within all fields of nursing.
The safe storage and management of medicines is an important aspect of the nurse’s role.
As a nursing student you must always be supervised by a registered nurse when administering medications.
Applying the eight rights of medication will aid you to optimize the medicinal treatment patients receive.
You must never give a medicine without being certain that the dosage (relating to the patient’s weight where appropriate), the method of administration, the route and the timing are all correct.
Patient empowerment with regard to their medication is fundamentally important.
Nurses need both the technical skills to accurately dispense medications and the mathematical skills to calculate the correct dose.
Malnutrition, or the risk of malnutrition, affects more than three million people in the UK. Admission to hospital increases this risk.
Undertaking nutritional screening using a validated tool and carrying out a full assessment are essential for all ‘at risk’ patients, especially when they are admitted to hospital.
Communication with the patient, family, carers and multi-disciplinary team is vital to promote a good outcome for the patient. This includes good record-keeping.
Providing a patient with adequate nutrition, including hydration, involves a person-centred, holistic approach on the part of the entire multi-disciplinary team.
As a nursing student you can assist a patient to choose healthy options and ensure they receive the appropriate food and drink safely.
Assisting a patient with their elimination requires the nurse to be aware of the professional, legal and ethical issues associated with performing intimate care.
Constipation has various signs and symptoms which nurses should be aware of in relation to their particular patient group.
The Bristol Stool Chart is a widely recognized tool in relation to bowel assessment.
A wide range of professional and local policies must be adhered to in relation to elimination needs.
The key function of micturition and the digestive system is the removal of waste products from the body.
As assisting a patient with their elimination needs involves dealing with bodily fluids, awareness of local infection prevention and control procedures is vital.
Maintaining a patient’s privacy and dignity is an essential component of all aspects of elimination care.
Assisting a patient to maintain their personal hygiene is at the heart of nursing care.
Performing the range of personal and intimate activities involved requires nursing knowledge and skill, but more than this, effective communication.
Maintaining hygiene involves activity throughout the whole of the patient’s day, not just at the start and end, promoting patient dignity, self-esteem and a positive body image.
The key clinical skill procedures you should be familiar with in terms of patient hygiene include how to perform a bed bath, assist a patient with a wash and undertake mouth, nail and hair care.
You will need to adapt hygiene practices to a variety of settings, while being mindful of the need to maintain patient dignity and independence and ensure their safety.
Care does not end at the point of death. Last Offices involves all the care that is given to a patient after death.
There are a range of cultural and spiritual considerations to be taken into account when performing Last Offices and caring for those who are recently bereaved. Ideally nurses will be aware of these before death and therefore prepared, but, unless there are legal reasons for not respecting such wishes, nurses must seek to meet the cultural needs of the patient and family.
Some deaths are referred to the coroner, which will affect the way in which Last Offices are carried out.
The role of the family in Last Offices is particularly important, particularly in relation to culture and the needs of bereaved parents.
When providing psychological care for bereaved family and friends remember that simple, caring nursing interventions and behaviours are appreciated by those whose loved one has died.
It is just as important to care for yourself as it is to care for patients and their loved ones.
This chapter has:
Discussed primary, secondary and tertiary levels of care.
Considered the role of community care.
Briefly outlined the development of the NHS.
Highlighted the shift from hospital care to primary care.
Identified the need for different parts of health and social care to effectively communicate and work together, in order to benefit patient care.
Focused upon one patient’s journey, highlighting their experiences through the three levels of care.
Identified a link between healthcare policy and organization and settings of care.
The health of the nation has changed over the past century and there is a need for a different approach to maintaining the health of populations.
Public health is very wide-reaching and encompasses promoting health, protecting health and treating illness. However, most health resources are spent on the latter and there needs to be a stronger shift towards promoting health.
Public health is about having a stronger focus on the population perspective.
Nurses need to understand the wider determinants of health in order to widen their health promotion practice.
Public health is about working across organizations and disciplines to improve health outcomes.
There needs to be much more focus on reducing the widening health inequalities between richer and poorer people.
Working in public health requires advocacy, communication and negotiation skills to influence policy.
Despite various reports stating that interprofessional communication/collaboration would prevent tragedies from occurring, this has not yet been fully achieved.
All professions’ standards make mention of interprofessional collaboration in some form.
Interprofessional working is complex and multi-faceted.
Understanding your own professional role as well as those of others is crucial to interprofessional collaboration.
Interprofessional dynamics mean that leadership of the team may create problems.
Team-building is crucial and time must be set aside for this.
Working interprofessionally must begin within undergraduate pre-registration programmes.
There are a number of different approaches in psychology.
Psychology is applicable to all fields of nursing and every patient interaction.
An understanding of child development will help you communicate appropriately with children of all ages, and will also assist communication with adults who have a learning disability.
Health psychology helps us to understand how people manage their health and illness.
Social support plays a crucial role in the care of patients with long-term conditions.
Nurses must ensure they always impart information effectively to patients.
Using PERFORM can help you apply and measure seven core psychological skills.
Sociology enables us to understand the social world.
There is value in nursing students studying sociology, so they can apply this to their practice.
Different sociological perspectives offer us alternative ways of understanding.
Sociology can help to challenge our assumptions and develop our critical thinking skills.
Clear links exist between sociological views and the development of nursing practice.
By encouraging us to question things we take for granted, sociology can help us to see other people’s perspectives.
An understanding of sociological concepts such as the family, poverty, disability and stigma enables us to deliver effective and holistic nursing care.
This chapter has:
Defined politics and health policy.
Identified nursing’s general lack of engagement in health policy.
Outlined the importance of education to ensure nurses develop political awareness.
Discussed how political ideology influences health policy.
Outlined how devolution affects health policy.
Identified a range of health policy themes.
Nursing, in any country worldwide, has more similarities than differences.
All nurses share a specific body of knowledge and skills which they implement within the confines of their specific environment to provide effective patient care.
Patient care must always be culturally competent.
Patients have a wide range of health beliefs that need to be considered to ensure the care they receive is acceptable.
It is not necessary to travel to faraway places to encounter cultural differences; the challenge of integrating differing beliefs is present in every patient encounter.
The NMC (2010) Standards enable nursing students to spend time on an international placement.
An international placement requires careful planning, but will greatly improve your nursing knowledge.