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?

[BonnieSc]

Just to broaden the discussion a bit I'll talk about where I've been in working in Africa... although it might defeat the purpose a bit because I don't want to say the name of the country (it's a small world and I prefer to stay anonymous). I have an outsider's perspective (worked in the system but didn't train in it). I could go on and on about the differences but here are a few...

--most nurses have a high school education and their jobs are similar to that of a nurse practitioner or physician assistant. Their last 2-3 years of high school were focused only on medical stuff. They examine, diagnose, prescribe, and then transfer if they realize the case is out of their hands.

--but these high school programs no longer exist. Now the entry into practice is a three-year diploma program, post-high school. The government offers scholarships to some nurses in order to up their level of education, but in most cases people have been able to keep their jobs with their basic levels of education.

--there's one bachelor's program and I think the goal will be to have everyone at a bachelor's level eventually.

--the country is training more physicians in the hopes that eventually the nurses will be nurses and there will be doctors to do that kind of work. There actually aren't different words for "nurse" and "doctor" in their language.

--in the major hospitals, the nurse's role is broadly similar to the US... hands-on care of patients, doctors' orders for medications, scans, labs. Despite the fact that previously (and by training) the nurses were autonomous, the hospital nurses are highly deferential to the doctors and end up being more like maids in some circumstances. Many doctors see bed baths as the primary function of the nurse (at least until something bad happens, then the nurse should have been doing more... sound familiar?).

--ratios vary hugely, from 1 to 8 or 10 in some hospitals to 1 to 30 in others. However, it's hard to explain, but the acuity isn't as high, and certainly the expectation for what the nurse should do is lower. Since a lot of things are not possible, the nurse isn't expected to do them (certain treatments and medications). And patients are often either "a little sick" or "too sick to help". The first set of patients don't require that much care and the latter patients are on some form of comfort care, whether that's acknowledged or not.

--in most cases, family are expected to help care for the hospitalized patients, and also to provide food for them; and sheets, towels, etc.

--in most cases, the patients pay for every item used. Boxes of gloves, needles for lab draws, packages of gauze. We charged the patients $1.50/day for bed baths at my hospital. Often the items have to be paid for before they are used. For instance, you can't receive a bag of IV fluids until you've bought it. And you can't leave the hospital until your bill is paid. Occasionally this resulted in police involvement.

--Nurses work at the mercy of the government. They can apply for different jobs, but they can also be transferred at will between departments or even different hospitals. The CNO does the hiring without input from the nurse managers (from what I observed).

--Working hours vary. One common pattern is that day shift works 7 AM to 5 PM and night shift works 5 PM to 7 AM. Other places work on 8 or 12 hour shifts. Generally, the night shift is allowed to (and they expect to) sleep for a few hours midshift. Which is important because they don't have permanent or even rotating shifts. At my hospital each nurse works two day shifts and two night shifts PER WEEK, for three weeks of the month. In the fourth week they only have three shifts (two days and a night, for instance). Exceptions are made in a few cases: some people like working nights and are allowed to work more, perhaps because they have a second job during the day; it's possible to get a health exemption of working nights is too physically difficult; and women who are in the last month of pregnancy (sometimes) or in the first year of breastfeeding get shorter hours and no night shift for several months. Every nurse I spoke to was satisfied with this arrangement and not interested in having permanent or rotating day/night shifts. (BTW there's no shift or weekend differential.)

--Students get MANY hours of clinical time. For instance, one set of third-year diploma students I worked with had 500 hours at my hospital for that semester. Fifty hours per week. Although they have clinical objectives (which are in some cases not realistic because the procedures are not being done in that country), mostly they are regarded as free labor. There's little supervision from school instructors and whether they get teaching from the nurses is hit-or-miss. Often the students come with "modern" ideas about nursing that the current nurses aren't familiar with, creating an even larger disconnect than we see in the US with that phenomenon. If I could only change ONE thing about the nursing system in the country it would be to reduce the clinical hours for the students. I think that would have positive ricocheting repercussions.

I hope that was interesting, and clear!

[babyNP., APRN]

I know some folks that were trained and worked in the US and then worked abroad in Australia and the UK. They've both said that the autonomy for nurses in those countries is much less than it is in the US. But then again, I think we probably have the most autonomous nursing workforce in the world. Certainly our nurse practitioners have much more independence than in other wealthy countries. But the role is still developing in those countries- in fact in the UK there is no separate license for being a NP; you just go to school for it.

[paidmydues]

Welcome! My WWII US Army Nurse mom used to say that Irish nurses were the best in the world! Am 61 y.o. Was an LPN in the 70s right out of high school. Then was a Flight Attendant for 25 years. Then back to RN school at 50. Patients/passengers...what's the difference??? Gosh miss the old Kardex system. It worked so well. Once you memorize common lab values, you'll be fine here. 6 pts to a ward room.....Yea I remember the 4 bed rooms at the VA hospitals in the 70's. They worked very well. Oh honey, the coddled American public wants their hospital stay to be more like a bleedin' 5 star hotel! Do you have to meet patient customer satisfaction scores? The bane of our existence. The PIXIS dear is kinda like a big candy machine that dispenses all kinds of goodies. It's really stupid though like most computers. It gets kicked and beaten often. The patients here order us around like their personal scut girls (and boys). Do they still have respect for nurses and call you Sister in Ireland?

Would love to have you come join us luv....again Welcome....

[vandiola]

I don't think their training is more intensive as we get waaaaaay more time in clinical training than us undergrads, but I do think their scope is wider. Most RN training actually seems to happen after graduation, as far as I can see on here, correct me if I'm wrong! Also I love the idea of being an ACNP, I would really LOVE that!

As for the NCLEX (I always think of it as en cee ell ex myself lol) I haven't looked at it but I did do some online CCRN mock ups and tbh I thought the questions were really easy - it's just things like lab values which are TOTALLY different that it would take me a while to get my head around!

I think it's because their academic side is considerably more intensive than that of England. At my university pharmacology is not a compulsory module, and its one of my weaker area's. I love the clinical aspect of my training and I'm so happy we're more hands than the US but a lot of the time students are just used as HCAs on wards and I'm rarely able to work with my mentors because they're so busy.

Also I'm so surprised they're still using kardexes in Ireland? Pretty much all over England theyre trying their hardest to computerise everything, which makes things 10,000x easier

[vandiola]

1. How do nurses become faculty members?

2. Do you have nurses in your operating rooms?

3. Do you have nurses in the community setting (home health)?

4. Do you think the low pay is due to being government employees?

1. In England you usually have to be in the process of doing masters research. At my university we do have quite a few PhDs and professors though.

2. Yeah we have theatre nurses who do all the scrubbing and circulating and assisting. We have anaesthetic nurses who assist the anaesthetists before patients enter the OR. And we have recovery nurses for post theatre care. You can rotate in all these areas if you wanted to or just stay in one area.

3. We have lots of different types of community nurses. So district nurses are the ones who go to people's houses and do dressing and administer meds. We also have school nurses, GP nurses, hospice and care home nurses etc Nurses in the community are far more autonomous in their practice than hospital nurses. I've met ANPs who prescribe meds, diagnose and refer pts to other services. We do have ANPs in hospitals but I've never seen them do anything more advanced than certain clinical procedures, like male caths and venepuncture.

4. The government doesnt give a shiz about nurses. We have socialised healthcare and nursing is the largest work sector, nursing pay is by far the biggest salary paid out to any other NHS profession. We have a weak union who dont support us and criticise nurses when they choose to strike with other unions. We have not had a real time pay rise in the past 6 years and everytime we bring pay up both the government and the public say we're greedy

[Silverdragon102, BSN]

I saw a big change with the pay when I started working in Canada, it almost doubled to what I was getting in the UK with over 15 years experience at that time. Before I moved to Canada back in 2007 I worked as a GP nurse and one of my colleagues became a NP and before I left she could do most things in the surgery as the GP's. She could order Xrays, prescribe narcotics, see her own patients etc. Here where I live it has only been in the last couple of years that NP's could prescribe narcotics.

Each nurse in each country has their own responsibilities and rules to follow. I find it great that we can sit here and discuss the differences which in turn can enhance the things we do for the people we look after

[walkingdeadhead]

When you say male caths, do you mean putting a Foley catheter in the bladder or something else? And is venipuncture inserting an IV, a central line, or a blood draw? Just wanted to make sure I understood what's considered advanced.

[Libby1987]

When you say male caths, do you mean putting a Foley catheter in the bladder or something else? And is venipuncture inserting an IV, a central line, or a blood draw? Just wanted to make sure I understood what's considered advanced.

I'm wondering that as well, venipunture (for labs) isn't even considered skilled. And male caths are usually much easier than female.

[Libby1987]

This is the most interesting thread!

Can you describe more about home health? Patient acuities, types of skills/procedures, job satisfaction?

[Parakeet]

Well! I wish I could have done nursing in a program like you describe! For me, it is so hard to comprehend the theory side, which seems to be the emphasis in the US. I learn best by hands on during clinicals; it would be amazing to have as many clinical hours as you do.

[beckster]

This does happen but is not routine.

[MrNurse(x2), ADN]

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?

I remember the med cart/ kardex system. It was really fast to give meds, but super unsafe. The scan and pyxis system almost eliminates blatant wrong med, wrong patient, wrong route errors. Given the horrendous patient ratios and expectations, this would be both time and cost prohibitive. That system would never fly here, where customer service is the most important indicator of excellence.