The analysis revealed two main themes: Return to nursing and The bridging program as a tool for transition to nursing in Sweden (see Table 2). The first theme includes conditions and experiences which the participants interpreted as important for achieving the goal to re-establish themselves as registered nurses in Sweden. Sub-themes are: Motivation and determination and Support from others. The second theme reveals the participants’ experiences of the bridging program and how the program aided and challenged their integration into the nursing profession and includes the sub-themes; New learnings and Disappointments, achievements and future plans.
Return to nursing
The goal to return to the nursing profession was consistently emphasized by all participants in the study; “It has always been my goal since I came to Sweden” (P3) or “My goal was to get the licence [to work as an RN] as soon as possible” (P8). However, the path leading to the start of the program varied in length, from only a couple of years up to almost 15 years. Seven of the participants started the program within a five-year period after arrival in Sweden. The participants described personal as well as social conditions they deemed important for a successful transition to the world of work as a nurse. Motivation and determination in terms of a clear understanding of essential preconditions and how to acquire them were important personal conditions, while support from formal and informal relations were important social conditions.
Motivation and determination
The participants presented themselves as persons with a strong will, who wanted to reach their goal to obtain Swedish registration as a nurse, and as persons who worked in a dedicated and purposeful way to achieve the goal. The participants described two basic conditions as important for reaching their goal: acquiring Swedish language competency and work experience from the Swedish health care sector.
Several of the students did not regard the Swedish language as an obstacle in itself for their life and studies. However, they recognized the importance of acquiring language competencies to succeed in the world of work. Therefore, they tried to find ways to acquire the language skills and qualifications that were needed. They had, sometimes very intensively, studied Swedish language from the beginning by starting basic courses in Swedish for immigrants (SFI) and then had continued to meet the requirements for academic level studies. They also developed different strategies to learn Swedish which included e.g., reading books, watching TV and spending time with Swedish-speaking friends.
You just have to keep trying and stay curious [ … ] and study like I do now. I’m not a person who says, ‘Okay I’m finished one with my education’ and close all books. No! I read every day, because I can read this paper today and then tomorrow [when I read it again] I will find new information that I didn’t find yesterday. [ … ] To learn a new language when you’re an adult is not easy, but we learn every day. I spend time with colleagues and Swedish people [to learn]. (P1).
Formal certificates confirming appropriate levels of Swedish were obtained through language courses (SFI), often specifically targeting immigrants with experience of working in healthcare. The courses also included practical language training at different health care establishments. These courses were described as significant by the informants for assisting them in their endeavour to work as an RN in Sweden, as they not only provided formal competence in Swedish language but also gave essential knowledge and insights about the Swedish healthcare system. Moreover, many of the participants also took extra measures to improve their knowledge and the chances of reaching their goal, either by working part-time in health care as assistant nurses and studying at the same time, or by taking complementary courses.
I started a course in basic Swedish [Swedish as a second language, SSL]. After one month, in March, I started to work as an assistant nurse, employed by the hour, and studied at the same time. When I finished basic Swedish, I was employed. I continued to study SSL levels 1, 2 and 3 as distance learning courses while working 85% at a retirement home. (P2)
The participants recognized that it was hard work, working and studying at the same time. But they were well aware that a successful transition demanded experience of working in Swedish health care and learning the Swedish language so they could manage the daily nursing practice. They reported the value of this hard work during the bridging program and subsequent transition to the world of work as it gave them not only language competence but also knowledge of the Swedish healthcare system. One of the participants described the experience she gained in Sweden before starting the bridging program as valuable because it made her aware that “[ …] I needed to develop my Swedish [ …] and I got an initial overview of the [Swedish] society and the differences in nursing compared to [country of origin]. (P3). However, the participants seldom explicitly described themselves as determined, but they often stated that “there is no other way, it just has to work out”.
Support from others
The participants described social relationships as significant for their experiences of the bridging program and their chances of a successful return to nursing. These contacts and relationships were both formal and informal in nature.
The participants’ experiences of support from the authorities varied. In some cases, the participants felt the authorities had, hindered them from striving to get the education they needed, or that they needed to take matters into their own hands.
They [officials at the Swedish public employment agency] asked me: ‘How did you manage to get a trainee position without our help?’ There were not pleased and wondered how I had managed to sidestep them. But I said, I’m here and I need your signature. I will not leave before I get the signature because I have found a trainee position. (P3)
However, the participants also spoke about other persons, i.e., their managers or supervisors where they worked, who had encouraged them and informed them about the possibilities to get the Swedish registration. For some of the participants, it had also been possible to receive their education during a leave of absence from their workplace. Some of the participants, primarily newly arrived refugees or asylum-seekers, were also targeted to more general investments for competence by the local authorities, for example ‘fast-track’ courses for healthcare professionals.
It was just a coincidence that I was accepted [to the language training program for newly arrived healthcare professionals]. I was playing football and a friend accidentally hit me over the ear, so I had to go to the district health care center. The nurse at the center knew I was a nurse and told me about the local project and she signed me up for it. [And later] I was accepted for the course. (P4)
These formal relationships and acts of encouragement described by the participants were important drivers in learning about the possibilities to supplement one’s education and to set favourable conditions for the bridging program.
Also, the informal networks and relationships helped the participants to manage the bridging program. Many of the participants had family responsibilities, material as well as emotional, that needed to be managed and fulfilled if they were to go back to school. During the education, several participants received their main support from their family members, especially from spouses or parents who took responsibility for the household tasks and childcare and shared economical expenses, so that the participants could devote all their time to their studies and pursue their goal.
Interviewer: What was it like to attend the bridging program while having small children, what did that demand from you?
Participant: Her [daughter’s] dad is with her all the time. If I need to relax and study, he’s with her. Sometimes, as a mother, I think that he is responsible for her and it is not my problem because I am a student. (P5)
The value of this social support system in bridging program was highlighted in several accounts, especially by those with families and children. The support was important for creating the possibility to devote the necessary time to studies. Support from spouses was also important for sharing the emotional and care responsibilities in the families that are traditionally accepted by mothers, which is illustrated well in the excerpt above. For participants both with and without family responsibilities, the support from fellow students was highlighted. The participants described the strength of being part of a program where they all shared occupational experiences and a common goal, despite their differences in terms of national background, gender, age etc. The differences were even described as a resource:
We all have different skills, experiences and capabilities but it was a really good student group because we worked together and helped each other. Some had worked for many years [as nurses] and others had not [ …] as a whole it was a really good group, we cooperated and assisted each other. [ …] We come from different countries and have different knowledge so of course we are different, but we give information, become friends and study together. (P6)
The participants could make use of each other’s competencies and knowledge to advance in the program and to encourage each other to keep striving.
The support from informal social relationships, such as family and friends and fellow students was emphasized as vital for encouraging and enabling their perseverance in the bridging program. For many participants the decision to enter a bridging program was a huge investment, both financially and emotionally, and the value they put on the support from near ones as a key to their success should not be understated. Formal social contacts and connections, such as public officials and authorities were mostly viewed as significant for learning about the formal requirements for working as an RN in Sweden and becoming familiar with the health care system.
The bridging program as a tool for transition to nursing in Sweden
All participants considered that taking part in the bridging program was a more reliable option for reaching the goal of working as an RN in Sweden, compared to preparing on their own for the test that precedes nurse registration. The program thus provided a clear path toward their goal and a chance to fulfil the requirements, and to learn about the Swedish healthcare system and the role of RNs. The general perception expressed was positive in terms of the program as a tool for reaching one’s goal, nevertheless, the participants also reflected on obstacles and drawbacks.
Attending the bridging program contributed more, according to the participants, to learning and understanding the differences in the scope of nursing practice in Sweden compared to their previous experiences. The main difference in nursing practice described by the participants concerned the relation between nurse and patient in daily practice. The autonomy of patients and the patient-centred care in Sweden were seen to differ greatly from what they had been used to.
The difference is that you must consider the whole person, not just the disease. I must always ask the patient before I do anything, get consent if I wish to examine him and ask if he wants the treatment. The patients have a right to decline treatment. That was most important to learn, that I must ask the patient before I do anything. It is different in Syria, where the patient is treated without consent. He is there [at the hospital] and [therefore] accepts treatment. (P7)
Many of the participants were not accustomed to the autonomy of the patients, and the need to confer with them before treating them. This was a new learning to handle, although they experienced it as positive. They recognized it to be important knowledge to acquire and that the bridging program contributed to the acquisition of that knowledge. Generally, the theoretical courses, which related to medical competencies and pharmacology, were seen by many as repetitive or affirmative of the knowledge they had already attained in their original nursing education and working life experience.
I didn’t learn much new about the medical aspects [of nursing] but I learned a lot about the [organisation of the] medical system and routines, how to write in the journals etc., because that is different everywhere. The medical aspects are universal, so I didn’t learn new things because I had already done so. (P10)
The participants regarded the practical courses as having a greater value for their learning and prospects of becoming a Swedish RN. The clinical training, which was part of the bridging program, was particularly appreciated. During clinical training the participants reported learning about the Swedish healthcare system, how healthcare care is organized in different establishments and how the forms of care differ, for example primary care, home care and hospital care. Clinical training also contributed to a deeper understanding of the scope of nursing, e.g., daily routines and assignments, relations to different professional groups that nurses collaborate with in daily practice, and work division between professional groups.
Clinical training is difficult, but it gets easier once you know more about your role, when I know what my job assignments are and what assignments the doctor has. But it takes time, I need more time [in clinical training] to feel confident, or how to put it. [ …] You learn in daily practice. If a group needs support for example, who does that? Is it perhaps the doctor? Or the assistant nurse? Or me? (P4)
The clinical training was described as challenging, but the participants still valued the learning that took place there rather than in classrooms. They had seen how the roles between doctors and nurses differed from their home countries, where the doctors had a more authoritarian role than in Sweden. To successfully adapt to the new role was time-consuming but was provided by the clinical training. The participants’ general stance was that this type of knowledge can only be acquired through experience of practical work and interaction at the different workplaces, as the scope of nursing and also the vocabulary varies between different hospital wards or healthcare establishments.
Those who work in medical wards use their special concepts and those who work in surgery have theirs. That is why I have suggested that the clinical training needs to last at least six months to give us a chance to see different wards. For example, I only spent ten days in home care and one month in primary care. That was not a lot of time [to learn]. (P4)
Clinical training also placed the participants in challenging situations, and they faced difficult assignments. The advanced materials nurses had access to and worked with in Swedish health care, e.g., the digital solutions, such as journal systems, presented a challenge. Some of them regarded this as a problem, as their technological knowledge was not that good. Journaling and documentation were also described as difficult because it challenged the participants’ language competencies.
I would put more focus on documentation. I think most of us have inadequate knowledge, not just me. [ …] When you sit down [to do it] you don’t know which box [to check] or what to write. It is difficult. I see how competent the nurses are. But I panic. It takes time for me and it stresses me out. [ …] Perhaps my colleagues will say ‘you have spelled this wrong or made a mistake here’. (P9)
As illustrated in the excerpt, the participants expressed insecurity about language competencies related to documentation and journaling, which were often seen as new routines, although central to the nurses’ scope of practice. Due to experiences like this the participants valued clinical practice and described it as a means to improve their language competency, technical knowledge and familiarity with work routines, and therefore requested more clinical practice during the bridging program.
Disappointments, achievements and future plans
As mentioned, the general experience of the bridging program amongst the participants taking part in this study was positive. The knowledge the participants gained throughout the course of the program, particularly during clinical practice, was identified as vital for a successful transition to the world of work and to re-establish oneself as an RN. Nonetheless, some participants also reported experiences of misunderstandings of their role and competencies during clinical practice. The participants described a lack of knowledge about the bridging program and the participants’ professional backgrounds among some of the supervisors.
Sometimes they [supervisors of clinical practice] do not understand what the bridging program is and the [competency] level we have. I tried to explain to my supervisor that I was not there for language training but for the bridging program and that I was already an educated nurse. But for four weeks she only addressed me as a ‘language learner’ [språkpraktikant]. (P7)
Not getting recognition for one’s professional competence while attending clinical practice due to the supervisor’s lack of knowledge is one example of the disappointing experiences the participants described.
A second example related to the uncertainties of the outcome of the program as it did not guarantee acquisition of a nursing licence from The National Board of Health and Welfare. One participant described how the language competencies of some of the participants were perceived by the supervisors in clinical practice as problematic and as affecting the participant’s ability to work as an RN. One participant said: ‘there were some problems during the clinical practice where they complained about our language competency and said that we should work as assistant nurses instead’ (P2). The same participant continued to question why the risk of not passing the program was delivered late and wished that the program directors had made this clear earlier. Although she did not worry about her own future, she expressed compassion for her fellow students who had not managed to get through the education. They all had invested much time and energy in the education, and she empathized with those for whom it had not “paid off”. For most of the participants though, having managed the education and especially the clinical training was both a relief and an achievement that they were proud of:
I was nervous up until the last day. When the examiner told me that I had passed [the program] I couldn’t believe what I’d heard so I had to ask her again. It was such an amazing feeling! I am proud and very glad that this was possible because it was a long journey, a really hard journey. (P3)
The possibility to work as a registered nurse while waiting for the registration was appreciated and anticipated. However, for 9 of the 11 participants, the bridging program was not the final goal but instead it had made possible new goals for their future and working life. Most of them planned to work as an RN for a few years to gain experience and then continue their education and become a specialist nurse in an area of particular interest. Especially popular was the idea of becoming a district nurse, but other specializations were also of interest:
In due time, I plan to continue my education and become a specialist nurse. [ …] Primarily to specialize as a district nurse, but it depends … perhaps specializing in diabetic care, asthmatic care or something like that. (P8)
My idea is to work at the hospital for a couple of years and then if all goes as planned, I will continue my education. [ …] My main interest is to specialize as a nurse in intensive care. (P6)