Differences in US nursing vs the rest of the world

[irishicugal]

Hi all! Can I just say, I'm fairly new to allnurses but I LOVE it, it's the automatic app that Siri now wants to open on my phone which means I'm probably on it a little too much... I understand the majority of nurses on here are from the US and I'm learning the many differences between US and European nursing (Google is my friend for all the acronyms, I genuinely had never heard of a BSC, ACNP or UHC...) and someone on another thread mentioned that they didn't think we had enough autonomy in Europe (we certainly don't get the same level of respect or pay!) I certainly don't intend this to become an argument as to which is "better," I am just interested to learn how things are done in other parts of the world. I'll outline how things are done in Ireland, where I am, and if someone could compare how things are different I'd be really interested! Many thanks (oh yeah and I'm REEEEEALLLY sorry for the long post!!)

Training: We have a four year degree programme, and it doesn't matter if you have a primary degree beforehand, there is no such thing as an accelerated BSN. Diplomas and certificates were gotten away with in 2004. We don't have enrolled nurses or LVN's, everyone trains as an RN. Clinical placements make up the majority of your college, increasing amounts each year. Each placement usually lasts for 6 weeks and you work 35 hours a week. In your final year you spend 9 months working 12 hour shifts alongside a preceptor, and are paid minimum wage for this time. They will also spend some time on night duty. Students do have a placement co-ordinator but staff nurses are obliged to precept students and the student basically "shadows" their preceptor, and takes on nursing tasks with the supervision of their staff nurse. Because of the large amount of time spent on placement, orientation is very short as a new grad, you're lucky to get 2 weeks, and if you stay on at the hospital where you trained, you rarely get any orientation at all - after all, you've worked there as an undergrad for 9 months!

Additional training: for some reason certain skills aren't included in our training and you have to do another course post qualification. These include IV antibiotic administration, phlebotomy and cannulation, male catheterisation and fine bore NG insertion (ryles are fine but I think they're worried the guide wire in fine bore might puncture a lung....)

Metrics: I have to admit I've used google a LOT to try and understand some of your diagnostic values. We are taught a normal blood sugar is between 4.5 and 7.0 (mmol/l), then I see posts of blood sugars being "only" 40 and I'm like whaaaat? Also, our p02 and pC02 measurements are different, creat. levels etc, I don't know if I'd ever get the hang of it if I jumped across the ocean to you guys!

Nursing ratio: I'm well jealous of many of the people on here. Our "ideal" assignment is 1 nurse to 6 patients, but frequently it is 1:10 and on nights it is 1:12 or even 1:14. With that, on med/surg there is often only one HCA for 32 patients. Many HCA's cannot take vitals and just help with personal care and feeding. They are certainly not allowed to do dressings. Even those who can do vitals are not allowed to do blood sugars. Nurses basically spend 12 or 13 hours running around! In ICU the ratio is 1:1, but "ICU" means vented, anyone who needs pressors but isn't vented goes to HDU or CCU. In the ICU we don't have RT's, the nurses handle the tubing, suctioning, vent settings etc. There are no HCA's in ICU, if care is 1:1, that one nurse has to do everything with the patient. LTC seems to be about the same, 1:24 or 1:30 but 4 or 5 HCA's to back you up...

Meds: This is where I see the most difference. We are so backwards! What is this pyxis I keep hearing about? On med/surg you have a drug trolley and bring it into each 6 bedded room (most of our patients are in 6 bedded "wards" the private rooms are kept for isolation cases) and give out your meds. We have a stock supply of many drugs, anything else you just ring and get from pharmacy. Drugs aren't assigned to a particular patient, you use the same box of aspirin for everyone lol. I actually don't understand when you say "pulling meds" and "returning meds" back to the pyxis, can someone explain it to me? Our drug kardexes are paper, and we sign in when drugs are administered.

Ordering: This is another area in which I'm confused. Someone on another thread mentioned that they didn't do a drug screen because the doctor hadn't ordered it. If we want to send a drug screen, we do. If we want to swab a wound or order bloods we do. If someone looks like they're going septic we'll draw blood cultures, sputum and urine etc, and just send them to the lab - we don't need a doctor's say so!! We can't order X-rays unless we have done a course in X ray prescribing. Also in the ICU, we ask the anaesthetists (ours are all doctors btw, we don't have nurse anaesthetists here) to chart electrolytes in the PRN section of the kardex. That way, if K or MgS04 is down, we just go ahead and replace without bothering anyone.

Post graduate training. The majority of our nurses train as a Registered General Nurse, but primary training also includes Registered Nurse Intellectual Disability and Registered Mental Health Nurse. If you want to work in paeds, maternity (Registered Midwife) or public health afterwards you must complete an 18 month Higher Diploma which leads to an additional entry on the register. If you work in a speciality such as ED or ICU it is expected that you will also undertake a post graduate course, usually at least 12 months duration. You can use this course to count towards a Master's qualification. New grads generally do NOT work in a speciality area, you need to get a year's post grad experience in med/surg before you can undertake any of these courses. There are also courses in education (Registered Nurse Tutor) and prescribing (Registered Nurse Prescriber)

Oh my, I could go on and on and on with even more differences but I realise I've rambled on for FAR too long. I just find it very interesting! What do other people think?

[Silverdragon102, BSN]

I have seen a big difference from UK to Canada mainly in Nova Scotia it is the shortage of GP's and they take their turn in Emerg covering and seeing patients as well as seeing their own patients on the wards/units. Thankfully I noticed most blood levels are similar to the UK as are the blood sugar monitoring and HbA1c. Some wound dressings are different and 1 we have started using a lot and was advertised/sold to us a new but I remember using it in the UK over 10 years ago.

Training for RN is done in NS at the universities and are 4 years long but they get the summer off and a few weeks over Christmas off where I remember just getting 3 weeks then working/studying 6 months before another 3 weeks off.

[Dohardthings]

Video on Pyxis.

[irishicugal]

Video on Pyxis.

Wow thanks! That's super cool technology! So you have a whole pharmacy of drugs already on the floor in case they are needed? But idk about the whole scanning and individualising thing. I can get a 12 person drug round done in around half an hour doing things the "old fashioned" way, I would imagine using this Pyxis (I was pronouncing it "pie-x-is" lol) takes a bit longer?

[Dohardthings]

Definitely slower, foooooor sure! But the whole system is to eliminate medical errors. Not all drugs are in the "Pyx-sis", just the more common ones. If we have a new patient and they take a drug more often than once and it is not in the Pyxis then it will be stocked and available for subsequent doses.

I couldn't imagine your patient load but thinking about how medicines are given here, it really isn't possible.

As for leeway, it depends on the facility and the physician and nurse dynamic. Our physician trust us if the patient is pooping 20 times an hour, then we will drop an order for a stool sample. Typically there are protocol orders so that we are not asking for every little thing.

[Dohardthings]

BTW, I don't know how long it takes seasoned nurses to pass meds. I'm a newbie and it takes me 2 hours to pass meds to 6 patients. Mostly because that is when they ask for something else while I am there and I do a quick physical assessment as well.

[HouTx, BSN, MSN, EdD]

This is such a great thread. Thank you irishicugal for starting it.

Bottom line - health care in the US is structured to accommodate our payment system, which has always seemed to be the highest priority. It gives me hope that Patient Safety seems to be gaining some traction, but hasn't overtaken payment yet. US physicians are still the absolute gatekeepers to health care. The vast majority of chargeable things (admission to hospital, clinical interventions, medications, supplies, tests, etc) have to be initiated by a physician's order. In some states, mid-levels (NPs & PAs) have nearly the same authority levels, but it's variable. Therefore, the entire "engine" of healthcare rests on a massive amount of documentation... we have as many (and sometimes more) people employed in the coding & billing departments as we do in clinical areas. And there is no standardized system - every insurance company has their own way of doing things .... so it is enormously complex just to get a bill out the door.

Another reason for massive documentation requirements - We're a very litigious society. There is no such thing as "fate" or "Gods will". If things do not turn out exactly as expected, it's always someone's fault... and that someone must be sued for millions of dollars. When this happens, all of the documentation is extracted and analyzed by both sides in order to prove their case.

Our healthcare accreditation agencies have also piled on a ludicrous amount of requirements - all of which require additional nursing documentation. They include mandates for a variety of things from vaccinations to management of central lines, ventilators & urinary catheters. . . the list increases each year.

So - it's no wonder that several years ago, the US embarked on a massive effort to digitize everything. At this point, any provider that doesn't have computer based charting, e-prescribing systems & electronic billing is subject to penalties (in terms of decreased reimbursement, of course). This may (eventually) simplify the business processes, but it has only served to increase "charting" time for nurses. Current studies reveal that about half of an acute care nurse's time is spent in documentation . . . so you can see why it would be simply impossible to manage higher patient loads unless we had stenographers following us around - hmm, now that's an idea!

Help! We're drowning in documentation. All of the technology that is introduced to 'streamline' cumbersome processes has only resulted in more computer interface (scanning, keyboarding, setting parameters, adjusting alarms, etc) time for the nurse.

[Farawyn]

Irish, LOVE your schooling and amount of clinical hours.

What happened to the LPNs and ADNs after 2004?

[Eleven011]

Very interesting thread! How I would have loved to be able to just "send up a lab" when I worked in LTC!

[irishicugal]

Irish, LOVE your schooling and amount of clinical hours.

What happened to the LPNs and ADNs after 2004?

Omg I'm fangirling here I just love your posts farawyn! LPN's (they were called enrolled nurses here) stopped training in the 80's but they were allowed to keep working until retirement. The ADN's or diploma nurses are still RN's and many of them haven't acquired their BSN, it's just that they no longer do that training in ireland. There's no obligation to get your BSN at all, and if you gain a post grad hDip in a speciality area you can progress to second year MSc without it - they take in to account your years of services and prior learning. Most older nurses don't have any post grad qualifications at all, and they don't need them - I'll take a 30 year experienced RN without higher education any day over a new grad with the alphabet soup after their name!!

[Farawyn]

Omg I'm fangirling here I just love your posts farawyn! LPN's (they were called enrolled nurses here) stopped training in the 80's but they were allowed to keep working until retirement. The ADN's or diploma nurses are still RN's and many of them haven't acquired their BSN, it's just that they no longer do that training in ireland. There's no obligation to get your BSN at all, and if you gain a post grad hDip in a speciality area you can progress to second year MSc without it - they take in to account your years of services and prior learning. Most older nurses don't have any post grad qualifications at all, and they don't need them - I'll take a 30 year experienced RN without higher education any day over a new grad with the alphabet soup after their name!!

Thank you!

So, they are grandfathered in? Are they expected to get a BSN, or just, we don't do this anymore, but since you're already a nurse, you're good?

I kind of like that idea...

[irishicugal]

This is such a great thread. Thank you irishicugal for starting it.

Bottom line - health care in the US is structured to accommodate our payment system, which has always seemed to be the highest priority. It gives me hope that Patient Safety seems to be gaining some traction, but hasn't overtaken payment yet. US physicians are still the absolute gatekeepers to health care. The vast majority of chargeable things (admission to hospital, clinical interventions, medications, supplies, tests, etc) have to be initiated by a physician's order. In some states, mid-levels (NPs & PAs) have nearly the same authority levels, but it's variable. Therefore, the entire "engine" of healthcare rests on a massive amount of documentation... we have as many (and sometimes more) people employed in the coding & billing departments as we do in clinical areas. And there is no standardized system - every insurance company has their own way of doing things .... so it is enormously complex just to get a bill out the door.

Another reason for massive documentation requirements - We're a very litigious society. There is no such thing as "fate" or "Gods will". If things do not turn out exactly as expected, it's always someone's fault... and that someone must be sued for millions of dollars. When this happens, all of the documentation is extracted and analyzed by both sides in order to prove their case.

Our healthcare accreditation agencies have also piled on a ludicrous amount of requirements - all of which require additional nursing documentation. They include mandates for a variety of things from vaccinations to management of central lines, ventilators & urinary catheters. . . the list increases each year.

So - it's no wonder that several years ago, the US embarked on a massive effort to digitize everything. At this point, any provider that doesn't have computer based charting, e-prescribing systems & electronic billing is subject to penalties (in terms of decreased reimbursement, of course). This may (eventually) simplify the business processes, but it has only served to increase "charting" time for nurses. Current studies reveal that about half of an acute care nurse's time is spent in documentation . . . so you can see why it would be simply impossible to manage higher patient loads unless we had stenographers following us around - hmm, now that's an idea!

Help! We're drowning in documentation. All of the technology that is introduced to 'streamline' cumbersome processes has only resulted in more computer interface (scanning, keyboarding, setting parameters, adjusting alarms, etc) time for the nurse.

We're drowning in documentation too! It's just actual pen and paper stuff. Nursing notes, communication sheets, individualised care plans, Waterlow assessments, falls risk, MUST, daily checklists.

I had heard that the US is sacrificing patient care for costs etc. Public healthcare is very cheap here, a max cost of €1000 per year for those who don't have private cover or health insurance. In a public hospital, there is no difference between private and public care, you don't get treated differently. If you're sick, you get what is needed. I also think we're not as scared of litigation. We don't CT every single person that bangs their head, for example.