Adjusting to a different life and a different way of nursing: travelling to the other side of the world to forge a new life and continue a nursing career has been both challenging end rewarding for a specialist intensive care nurse from Germany.

It has been a fascinating journey from business administrator in the city of Ludwigsburg western Germany to nurse in Christchurch Hospital's intensive care unit (ICU). But that's the journey 42-year-old Marcus Obele has undertaken, arriving in New Zealand with a smattering of English and a Kiwi wife, in late 2001. Before coming to New Zealand, he had worked as an ICU specialist nurse in a 1200-bed hospital in Ludwigsburg. The hospital was one of many serving the two million population living within a 50 kilometre radius of the city.

Obele began his working life as a business administrator but when he was called up for compulsory military training, he chose the "social duty" option available to those who did not want to do military training. He worked for 20 months in a psychiatric hospital providing basic nursing cares to patients. "I found it quite rewarding, particularly after my business job which was quite boring, with a lot of clock watching."

Hospital-based training

So he embarked on his three-year, hospital-based training, which involved one day of theory a week, 1200 hours over three years, and the remainder in the wards. "Training on the job, like I did, means that within two or three months you know whether you are nursing material or not. Here, many won't find that out until they have finished training. And we were paid for our training, we didn't have to get huge student Loans to become a nurse."

Once he graduated in 1989, he continued working at the same hospital first in gastroenterology and then in ICU, where he remained until he came to New Zealand.

While in ICU in Germany, Obele undertook a two-year intensive care course, involving 1200 hours of theory and all aspects of ICU care: cardiology, trauma, general intensive care, dialysis. "It was a very intensive course with an exam at the end. If you passed, you qualified as an ICU specialist nurse."

Obele remained as an ICU specialist nurse until his departure from Germany. He had met his New Zealand wife Mary, a doctor, through a medical colleague in ICU. He couldn't speak English--"I was lazy at school"--and Mary couldn't speak German, so they taught each other their respective languages. Mary couldn't find work in Germany at the time, the late '90s, as there were 10,000 unemployed doctors, so she did locums in London, between trips back to Germany. A qualified paediatrician, Mary did not want to work the punishing hours expected of consultants, so the couple decided to try "the other end of the world", arriving in New Zealand in October 2001.

For the next year, Obele focused on Learning English. A "merciless" neighbour in Oxford, north Canterbury, was his tutor and after a year he sat his occupational English test in Auckland. It consisted of four sections--listening, writing, reading and talking--focused on health and he passed with four A grades. The Nursing Council then required he be assessed to ascertain whether he had sufficient knowledge to gain registration here. He did three weeks unpaid work at Burwood Hospital and then got his registration. In February 2003 he began work in the ICU at Christchurch Hospital. And that was a significant nursing culture shock.

"My first impression was that there was a lot of staff. Here there is one nurse to one patient, but that would be far too expensive in Germany, where there would be one nurse to up to five patients. Another big difference is here there are medical technicians who deal with all aspects of the ventilators whereas in Germany we dismantle the ventilators, clean them and put them back together again. In Germany we didn't have orderlies and did all our own patient transportation."

And the nursing care was different too. "At first the care here seemed quite fragmented. I found it more satisfying in Germany where we were allowed to take more responsibility. And what I did as a nurse in Germany was more focused on caring rather than medical procedures. We would find out if the patient liked chamomile or peppermint tea, for example, and use that in the patient's mouth cares.

Different ethical considerations

The concepts of basal stimulation and kinaesthetics were very much part of nursing care in the hospital in which Obele worked. "One special clinic in Germany claims that two thirds of its comatose patients come out of their comas through intense nursing care using these techniques. Because of what happened in the Second World War, ethical considerations regarding the prolongation of life are different in Germany. Nobody would switch a ventilator off. We would resuscitate a very sick 90-year-old," Obele explained.

He gets frustrated by the protocols which abound here. "There are protocols for everything. It's as though nurses aren't expected to think any more."

He has an interesting observation about doctor/nurse relationships. "In New Zealand we call the doctors by their first names and superficially it seems a more equal relationship, but I think it is actually a more hierarchical system than in Germany. Doctors and nurses are more separated here, with doctors doing their business and nurses doing their work. When I ask questions I get the feeling that it is not my business. In Germany we went on rounds with the doctors, asked questions and had real discussions with them over patient care."

Making adjustments

So Obele has had to make many adjustments. "I had many heated discussions with doctors and consultants, but realised that I couldn't change the system. Germans are direct and some people can find that difficult. It may be a cultural thing, not just something within the hospital environment. I have had to adjust and have had to accept the way things are done here."

Despite such differences, Obele finds the whole system more humane here. "When my mother died, everybody was so supportive. In Germany, I would have had one day off to go to the funeral but here I had as much time off as I needed. The attitude was "if you want longer, that's no problem" And all my colleagues were so kind."

He also appreciates the more easy going, relaxed style here. "In Germany, you can't bend the rules. Recently we had a patient and his life was his little dog. The attitude was to make it possible for him to see his dog and that happened. He was delighted and it really helped his recovery. That just wouldn't happen in Germany."

He found the staff of the Immigration Service here very welcoming and friendly, a stark contrast to his wife's experience in Germany. "I went with Mary to the service in Germany and wondered why there were any foreigners in Germany, the staff were so rude."

He has never encountered any prejudice or negative attitudes from people he has nursed. "Many have been to Germany and that is a launching pad for conversation."

Obele still finds speaking on the phone difficult. "You can't pick up on a person's body language and if a person is speaking really really fast, I often find it quite hard to understand. Person-to-person it is always possible, but the phone is a barrier."

Another language difficulty is the widespread use of abbreviations in medical and nursing terminology. "English-speaking countries are famous for their abbreviations. When somebody referred to a BKA [below knee amputation] I didn't know what they meant. I have many books on abbreviations in medical terminology."

The German health system is a public health system, with no waiting lists. "If a procedure is necessary, it is done immediately or in a few weeks. But Germans pay 12 to 15 percent of their income per month, in my case $500, along with an equal employer contribution, for health insurance."

The system is under a great deal of financial pressure at present, and many nurses are leaving for work overseas. Obele now has four German colleagues at ICU in Christchurch. Five years ago, gross pay and conditions in Germany and New Zealand were roughly comparable, Obele said. "But in the meantime conditions have declined in Germany, eg the night shift bonus is now taxed, which is a considerable reduction, and New Zealand hospital nurses have had a significant pay rise."

While German nurses receive six weeks' paid holiday and sick leave, it is very difficult to work part-time, 12-hour shifts are forbidden and cost cuts are having a major impact at ward level. "The German nursing union is in defence mode. Working conditions in hospital are better here. And there is better equipment here, more expensive dressings and things like that."

In his ICU role, Obele has worked with many students and he has some doubts about nursing education. "The link between theory and practice is often missing. Translating what you have learnt theoretically to actual patient care is very different."

Earlier this year Obele was the subject of a random Nursing Council audit of his competence. His frustration at the process is still palpable. He fulfilled all the criteria but said the paperwork required was insane. "I wouldn't have known what the Nursing Council wanted but fortunately the hospital provided a rough guide of what was required. It was four pages of hot air and waffle. I followed it and answered the same questions over and over again. I spent hours on my self assessment which was just waffle. How does that benefit anyone?" He also found the timing of the audit, over the December/January holiday period, very difficult. He completed the "ridiculous" paperwork in time but did not hear from the Nursing Council With his practising certificate running out on March 31, he rang the Council on March 20 and was told he had satisfied its competence requirements.

Despite some frustrations about inter-professional relationships, systems and protocols, the benefits of working and living in New Zealand outweigh any negative aspects. He has forged friendships and a new lifestyle in his new country.

The United Nations'

He describes the ICU as the "United Nations", with its Russian, South African, Dutch and American nurses, along with the other German nurses and the New Zealand contingent. A mini Oktoberfest in his north Canterbury garage last year was a chance to celebrate the beer, the food, the decorations and the music of his home country with friends and colleagues.

The greater informality both within the health system and society, the flexibility of his working hours, the quality of life, the lack of traffic, the space, the ability to afford a house with a garden, all add up to convince him he made the right choice for himself and his family--he is now the father of two Kiwi-born sons, aged two and five months--in coming to the other side of the world to continue his nursing career.

By co-editor Teresa O'Connor