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My clinical experience alongside a Norwegian nursing student culminated this afternoon. I was fortunate to be paired with Nagma, an enthusiastic and friendly student who is graduating from nursing school in 3 weeks. Her final clinical is in the home health setting, so each day we have been part of the team that travels to residences in the north region. Today we saw two patients who we’ve previously visited! We took the subway to get to this particular area, and then walked to both apartments from there. One of our patients is a paraplegic and just moved to Oslo to receive better care. The home health facility has taken care of this patient since she arrived a month ago, and has required that two nurses visit her at a time. This directly correlates with public health core competency 2B12, “implements strategies for continuous quality improvements”(The Council on Linkages between Academia and Public Health Practice, 2014). The patient actually remarked how she is not used to such good care and multiple nurses coming to her home, as she lived in a smaller town with more limited access. There are many other examples I have witnessed of extra efforts the nurses make within the home health setting in Norway to improve the quality of care for their patients, such as making them food to help ensure they will eat. Many of the patients we saw over the course of the last three days are elderly and alone, so this small effort by the nurses goes a long way. 

My remarks about food preparation actually correspond with the SDG Goal 2, Zero Hunger. Often, hunger is related to lack of access. Normally we wouldn’t think of those in Norway, a developed country, having lack of access to food or being hungry, as a large percentage of those who are hungry are in developing countries (United Nations, n.d.). However, many of the elderly patients we visited were given access to food by the nurses from the home health agency. The nurses often prepare and order food for the patients, as many cannot make or order food themselves. Therefore, they totally rely on these nurses for food access and security, as these patients still technically live independently. The elderly are often considered a vulnerable population and it is reassuring to see that this home health agency has identified food access as a need and has stepped up to help alleviate the issue. This approach will likely need to continue, as by 2030, it is predicted that 1/3 of Norwegian municipalities will have 1/4 of their residents over the age of 67 (Royal Norwegian Ministry of Labour and Social Affairs, 2016). 

As a future family nurse practitioner, I will be treating patients throughout the lifespan. This includes patients who live independently but may have other needs impacting their health, especially those related to their home environment/situation. I have a responsibility to ensure their needs are being met, whether I can help them directly or provide them with the appropriate resources to assist in addressing all of their needs. For example, if I assess a patient and notice they are consistently losing weight, I can try to figure out their home situation in regards to food access, cooking options, and transportation difficulties. I could also coordinate with a nutritionist or dietician to assist in ensuring their dietary needs are being met. This of course would happen after I have ruled out medical causes. 

All in all, I am so grateful to have worked with Nagma these last few days and to be given the opportunity to witness how home health works in Norway. I look forward to the rest of the trip!

Nagma, my Norwegian student, in front of the home health office.

The Council on Linkages between Academia and Public Health Practice. (2014, June 26). Core competencies for public health professionals. Retrieved from http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf 

Royal Norwegian Ministry of Labour and Social Affairs. (2016, June). UNECE National Report on Ageing 2016- Norway. Retrieved from https://www.unece.org/fileadmin/DAM/pau/age/country_rpts/2017/NOR_report.pdf

United Nations. (n.d.). Sustainable Development Goals. Retrieved May 9, 2019, from

https://www.un.org/sustainabledevelopment/hunger

*Written by Alexis Garybush*

Yesterday was my first day working with Norwegian nursing students for our community clinical rotation. After we were briefed and received our assignments for the day, my student and I were off to provide care to residents within the assisted living community (located on the school campus) as well as in their homes around the neighborhood. Rather than logging into a computer to see patient information, my student had an iPhone that gave her the H&P of each patient, what needed to be completed during our visits, and within what timeframe each task should be completed. If we needed directions to a patient’s house, the iPhone was our guide. In some instances, biking to a residence is an option if it is too long of a walk.

It was very interesting to see how the student interacted with each patient; it was almost as if they were taking care of a loved one. We helped patients out of bed, assisted with their ADL’s, gave them medicine and even prepared breakfast for them in some instances. This approach to caring for patients is in line with Public Health Core Competencies 5B4 and 5B5; establishing relationships to improve health in a community (e.g., partnerships with organizations serving the same population, academic institutions) and maintaining relationships that improve health in a community. The dynamic of students working with residents on their campus and within surrounding neighborhoods allows aspiring nurses to know what is needed within the community in which they live. The last assignment of the day was not a home visit, rather a call to an elderly man in the neighborhood to make sure that he was doing alright. The relationships that are built between these students and their patients improve not only the physical health of the community, but the emotional health and wellbeing of the community as well.

During our day, my Fitbit reached 10,000 steps much earlier than it normally does (or somedays, if at all!). It really made me appreciate the walkability of the city of Oslo and how our students reach patients by walking, riding a bike, or taking public transit rather than driving from location to location as we are so accustomed to in the USA. The UN’s 11^th Sustainable Development Goal, Sustainable Cities and Communities, is definitely a highlight of my clinical experience here.

Chris, Katie, Kira, and Amanda on foot; ample bike rental stations around the city

Having access to a basic service such as public transportation cuts back on air pollution and energy consumption of cars, and having safe walkways and biking paths are an important component to walking to work or school rather than driving.  In some areas of Dayton, OH, there aren’t any accessible sidewalks, and so even if your job is only a mile or so away, it could be dangerous to walk the narrow and busy streets. Two of the target goals that are being met in SDG 11 in Oslo are: 11.2: “Access to safe, affordable, accessible, and sustainable transport systems for all, improving road safety”, and 11.7: “Provide universal access to safe, inclusive, and accessible, green and public spaces…”.

Me, waiting for the bus

My clinical experience relates to my future as an APRN because it allows me to have a better idea of what community and home health care take into consideration. Although I will likely see patients in an office or hospital setting, each of them will have a unique home experience. Some patients may be in need of assistance at home but do not receive any support. Some residents within my community may not have access to public transportation that would allow them to receive the care that they need. I think it is important to keep this in mind as an APRN because outreach is the key to encouraging preventative care, and back home it is even more important to do so as our clients may not have the option to walk to a clinic or have access to public transit get to their provider to be seen.

Yesterday was an amazing opportunity and I am learning so much about Norwegian culture and their perspective of healthcare. I can’t wait to learn more in the coming days!

The Council on Linkages between Academia and Public Health Practice (2014, June 26). Core competencies for public health professionals. Retrieved from http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf

United Nations (n.d.). Goal 11: Sustainable Cities and Communities. Retrieved from https://www.un.org/sustainabledevelopment/cities/

Today started our first of three days doing our community health rotation. I had the pleasure of meeting a Lovisenberg nursing student and joining her community health rotation! Her and another nursing student are participating in home health. We walked to the nursing facility every morning to get report and their assignment, and then walked or biked to their patient’s apartments or homes. It is really neat how they can travel from home to home in close neighborhoods on foot! They each have smartphones from the facility that they carry on them in order to chart, review meds, and write notes in real time. They use these phones as well to go over the patient’s data with them in an easy-to-read manner. This directly aligns with the public health core competency 3A2: ” Communicates in writing and orally with linguistic and cultural proficiency (e.g., using age-appropriate materials, incorporating images)”. The students spent a lot of time talking to the patients about their care and  reviewing their progress. The charts on the phone include graphs and scatter plots of their data. In addition, it tells them all the tasks the patients require and about how much time it will take. It is a great use of technology!

During lunch we started talking about the Sustainable Development Goal of gender equality. Similar to the US, Norway’s nursing population is primarily women. Men are encouraged to join the nursing workforce by receiving more “points” towards their application if they are male. The opposite is true with women in engineering- you get more points for being a female when applying to be an engineer. Despite the push for equality, women make less money than men. The Norwegian students explained that there is approximately 1 day per year that women “work for free” compared to men.

Though there is also a wage gap in Norway, they surpasses in terms of women in politics. There is currently a woman seated as prime minister (and she is the second woman!) There is also a push for increase women in parliament, and people are supporting policies that would mandate a requirement for certain number of women in the workplace.

This experience relates to my future as an advanced nurse practitioner in learning about the different home environments that newborns can be sent home to. There were definitely some safety issues in the home I saw to be addressed for newborn populations. I think that it is important to have home environments baby-proofed before infants are sent home. In houses in Norway, there were a lot of antique glass wear, old furniture, power cords, and vintage rugs. Even though I saw a lot of older patients today, it would be interesting to see what a home looks like young, new family.

It was a great first community clinical day! I really enjoyed being able to see the inside of Norwegian homes and how home health care works.

Walking around the neighborhood where we did home visits

Guro (Norway), Christina (US), and Emilie (Norway) in front of the nursing center

Me and Christina in front of the nursing center

United Nations (n.d.). Goal 5: Achieve gender equality and empower all women and girls. Retrieved from https://www.un.org/sustainabledevelopment/cities/

The Council on Linkages between Academia and Public Health Practice (2014, June 26). Core competencies for public health professionals. Retrieved from http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf

The eleventh Sustainable Development Goal focuses on sustainable cities and communities, which emphasizes inclusive, safe, resilient, and sustainable cities and human settlements (United Nations). While we have only been in Oslo for a day and a half, the goal of creating a sustainable community is clearly evident throughout the culture. 

We spent the afternoon completing a “Windshield Survey”, a walking survey of the city where we assess the apparent health needs of the community by observing the structure and infrastructure, noting what is health promoting, and what may detract from the health of the community. We walked from the East to the West side of Oslo with a group of Norwegian students and could see the economic divide present in the city. Despite this divide, we still observed public transportation, clean streets, and active, bicycling Norwegians out-and-about. 

As we were chatting with the students from Norway, we learned that very few citizens actually own and drive their own cars—and they were shocked when we shared that we all have our own vehicle. As a sustainable nation, Norway utilizes biofuel, created from food waste, to power the public transportation and lessen greenhouse gas emissions. We took these fuel-efficient busses over to the grocery store, where I noticed there were almost no plastic wrappings on the produce and everyone brings their own reusable grocery bag (and you have to pay for a plastic bag if you forget yours!). 

Everywhere I looked on the walk home, I observed active Norwegians out walking, biking, and running. I have not seen a single overweight individual. The focus on sustainability extends to the people themselves—they emphasize a healthy lifestyle and have a significantly lower rate of chronic health issues (like diabetes and heart disease) as compared to the United States to show for it. 

As this second day comes to a close, I find myself reflecting on just how wonderful it feels to be in a community who embrace sustainable energy methods, work toward creating a healthy population, and are actively inclusive to all who come to this country. I can already see how I will take these concepts with me and apply them to my future as a nurse as I return home. Creating a sustainable environment for patients goes beyond the obvious (i.e. lessening the single-use, throw away society) and extends to the patients themselves. These active Norwegians remind me of the importance of educating patients on the importance of a healthy lifestyle—walking and biking not only help the individual, but play into the sustainable community by lessening dependence on fossil fuels in our cars and busses. I can’t wait to begin our Clinical experience tomorrow and continue to learn and love the country of Norway.

Group of students outside the University Hospital.

Beautiful waterfront, with lots of walking paths and outdoor markets.

Blooming flowers in the Sculpture Park gardens.

United Nations, (2019). Sustainable development goals: Sustainable cities and human settlements. Retrieved from, https://sustainabledevelopment.un.org/?menu=1300

Other than having feelings of exhaustion and a little jet lag from the 6-hour time difference and lengthy airplane ride, I can say we have made it safely to our final destination in Oslo, Norway. We all got great rest last night and are ready to embark on our adventure!

Yesterday was a day dedicated to figuring things out. Figuring out how the bus transportation works, getting our groceries for the week, and getting the chance to meet a few of the LDUC nursing students that we will be working with over the next couple of weeks. We spent the afternoon going to the Vigeland sculpture park and split up into small groups, with each group having a LDUC student as our guide.

Being here for such a short amount of time, I have already seen the ways in which the public health competency 1B11 to, “Identify the assets and resources that can be used for improving the health of a community” is being achieved (The Council on Linkages Between Academia and Public Health Practice, 2014). One example of this was visiting the Vigeland Sculpture Park. This park encompasses Gustav Vigeland’s life work, with around 200 sculptures in total that reflect the diversity of human experiences and relationships across the lifespan. Initially, I was surprised at how expansive the park was, and could not even think of a single park in our community at home that could compare. Something we noticed was how much green space there was beyond the sculptures. We saw lots of tourists walking along the sculpture walkway as well as many locals walking, biking, and playing games on the green space that expanded for what seemed like miles on either side of the sculptures. It was clear the space was vital to the health and wellbeing of visitors and locals alike by encouraging physical activity, social interaction, and getting people to spend a lot of time outdoors.

Photo from Vigeland Sculpture park that depicts a taste of how expansive the park was and amount of green spaces.

Since we have arrived, it has been evident that Oslo embodies the sustainable development goal number 11 for sustainable cities and communities (United Nations). They achieve this in several ways, but what has been most prominent in the last 24 hours is the number of people who walk, bike, and use the public transportation systems provided rather than using cars. Beyond this, they really encourage the use of electric cars rather than traditional cars by giving tax exemptions and parking privileges to those who have electric cars. From talking to the students, it seems parking and driving in the city is very challenging, so it does not even make sense for people who live here to use cars as their main way of transportation. For those who do drive in the city, they have created tunnels that direct cars away from places that have a lot of pedestrian traffic, making the city even more walkable. It is not unusual to see streets through the city center with filled lots of people walking through rather than cars. By having these resources in place, they are able to have less air pollution from car exhaust. We have all been joking that the air seems so much cleaner here, but I believe there is a lot of truth to that. The transportation system seems to be directly influencing the environment in a positive way.

An example of an alternative transportation to driving cars in Oslo, the streetcar.

A street near the city center – it was interesting to see only people walking in the streets and no cars.

Another, more modern, mode of transportation in Oslo – motorized scooters.

We also had the opportunity to visit a small grocery store near our hotel. At the store, you needed to purchase plastic bags. I thought this was a great incentive to bring in your own bags and contribute to less plastic waste, as the current way our society uses plastic is not sustainable. It will be interesting to observe the other ways Oslo strives for the sustainable cities and communities SDG in the coming weeks.

Sources:
United Nations (n.d.). Goal 11: Make cities inclusive, safe, resilient and sustainable. Retrieved from https://www.un.org/sustainabledevelopment/cities/

The Council on Linkages between Academia and Public Health Practice (2014, June 26). Core competencies for public health professionals. Retrieved from http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf

I chose to enroll in the Norway experience because I have found a passion in directly learning about cultures different than my own. One idea that truly resonates with me is being hands-on in my learning experiences. As Dr. Morrison-Beedy writes in one of her posts:  “You have heard these words in the classroom and discussed them, but now it’s time to put them into action. Your ability to effectively interact with people of different cultures, integrating respect and responsiveness, will take you far in this experience and those that follow” (1). We have been lectured on topics such as culture competency, unbiased versus biased behavior in healthcare, and so on. For me personally, I can study and read all about these topics, but it requires visceral experiences to fully learn, understand, and then incorporate into my practice these ideas we are taught on paper. I am excited and prepared to have these experiences in my repertoire to care for future patients in the best manner possible.  I strive to become a well-rounded practitioner in not only my skill set, but also my overall understanding of unique human cultures and behaviors.

Image retrieved from: Winters, M-F. (2014). Cultural Competence – Part 4: You Have To Do The Work. The Inclusion Solution. Accessed 7 May 2019. http://www.theinclusionsolution.me/cultural-competence-part-4-you-have-to-do-the-work/

I believe my past experiences abroad will help me mentally, physically, and emotionally prepare for this trip. Having been outside of the United States a few times, I can personally attest to many of the advice points Dr. Morrison-Beedy describes. I also have an extremely go-with-the-flow attitude in matters I know I cannot control. I understand that it is very easy to get upset about delays, changes in plans, etc., but if there is nothing you can do to solve the problem, why waste brain power on it? Travel (and life) can be simplified by keeping calm and collected, realizing that there are many different ways to find the experience you are looking for. In addition, do not discount the numerous avenues in which you can learn from experiences. Every interaction or situation may not be the most enjoyable, but understanding and recognizing the information you can learn from can make any situation/experience meaningful.

Top of the Duomo in Florence- My first time out of the U.S. during a study abroad in high school to various cities in Italy (2013)

John Lennon Wall in Prague, Czech Republic- my second study abroad trip (2016)

I am looking forward to immersing myself in Norway!

(1) Morrison-Beedy, D. (2019, February 4). The top 10 things to pack (in your brain) for global education experiences. Retrieved from https://u.osu.edu/osuglobaltransformations/

I am passionate about travel because it has had a large impact on the person I am today. So far, I have had the privilege of traveling to 6 different countries: Italy (2007), Costa Rica (2011), Peru (2014), Germany (2016), Haiti (2017), and Iceland (2017). In just a couple of weeks, I will be embarking on a new adventure as I travel to Oslo, Norway with my fellow nursing classmates. Traveling in the past has encouraged me to be more conscious of how I can be a better global citizen. Becoming a “good” global citizen is an aspect of myself that is ever-evolving, requiring self-awareness and openness to change.

With each of my experiences abroad I feel more and more confident in my ability to shed the “ugly American” sentiment that harms global relationships and adopt a more thoughtful way of traveling. Reflecting back on my previous trips, I can see how I have grown from being oblivious to what terms like cultural humility even mean to now being able to live out the principles practically. At first, adopting this new attitude and way of thinking towards traveling felt uncomfortable. Going to Peru for a service-learning trip was the first time I began aligning my new thinking with my actions. In Peru, I learned that being open, flexible and having a positive attitude when traveling to another country makes all the difference. One example of this that stuck out to me during my experience in Peru was seeing that most people in the town we were staying in did not own any clocks. As a result, I experienced time very differently in the two weeks I was there, learned a great deal of patience, and the importance of slowing down. If I had the attitude of an “ugly American” going into that trip, I would have been very frustrated with the differences between the USA and Peru rather than celebrating those differences. We limit ourselves and the ability of our experience to transform us when we travel as “ugly Americans.”

As someone who is passionate about global health and learning about cultures different than my own, I was eager to apply for the nursing experience in Oslo, Norway when the opportunity was presented to me. I am also drawn to their unique health care system and desire to learn more about how they care for their aging population as a future Adult-Geriatric Primary Care Nurse Practitioner (AGPCNP). Through this course I will be able to further develop my communication skills interacting with others from different cultures, which will translate well into my future practice as an AGPCNP where being able to interact with diverse populations is crucial to delivering quality patient care to all of my patients who will come from many different backgrounds. I hope to gain new perspectives on delivering health care that I could potentially implement into my future practice.

When in Norway, I will share my flexible, go-with-the-flow attitude I have gained from traveling to other places with my fellow classmates to help foster a mindset that is open to changes in the schedule that often naturally occur when traveling abroad. I will also strive to fully engage in the experience to contribute to the enrichment of the course. I look forward to making more memories in Norway and embody what it means to be a good global citizen!

Some of my favorite memories from previous trips:

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