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?

[MrNurse(x2), ADN]

Hello everybody!

I hope this all makes sense since I'm not an english native speaker.

I thought you were an American doing foreign study. Excellent grammar and sentence structure. Thanks for your perspective.

[Hollybobs]

I think we're allowed mittens, don't think it's considered a restraint... I'd have to check the policy book on that one!

Mittens are considered restraints in the UK.

Regardless of policies regarding deciding whether mittens are restraints, they ARE restraints. If I am wearing mittens and I want to pull out my A-line, drink my shampoo, scratch someone, hold a cup of tea, scratch my nose, I am restrained from doing so. I didn't put them on and I cannot carry out what I want to do because of them.

[irishicugal]

Mittens are considered restraints in the UK.

Regardless of policies regarding deciding whether mittens are restraints, they ARE restraints. If I am wearing mittens and I want to pull out my A-line, drink my shampoo, scratch someone, hold a cup of tea, scratch my nose, I am restrained from doing so. I didn't put them on and I cannot carry out what I want to do because of them.

Yes, I checked actually... [emoji15] Mittens are allowed but only to prevent contractures or sores in someone who is paralysed and vented. We can't put them on a LOL with dementia, in that case it's a restraint.

[irishicugal]

Hello everybody!

I'm Alicia, a second year nursing student from Spain.

Since no one here has commented anything about how it is to study nursing in Spain, I'll do it.

Here, since 2009, we have a four year degree. Each year divided in two semesters.

First year is all general themed, anatomy, physics, physiology, pathology, biochemistry, nutrition, english and some more. But the last month of the schooling year we get to go to a public healthcare center. There we're only allowed to do the simple things like, take temperature, blood sugar, blood pressure, weight and measure patients, among other little things like prepare meds. Since the 120 of us go to different centers some get to do more than others, for example, I got to do home visits, do shifts in the er, do appoinments on my own and even vaccinated in adults and pediactrics, but some of my friends didn't get to do half of what I did.

Second year gets more nursing oriented. We have this subjects called "Farmacología y dietética, Enfermería Clínica, Salud Pública y Comunitaria, Gestión, Ética y Legislación Sanitaria, Psicología, Bases Teóricas y Metodológicas de la Enfermería y Prácticas Clínicas": Pharmacology and Dietetics; Clinical Nursing; Public and Community Health; Management, Ethics and Health Legislation; Psychology; Theoretical and Methodological Foundations of Nursing and Clinical Practice.

Every subject has two different parts, a theorical one and a practical one.

This second year we're taught how to suture, bandages and plasters, different examinations and tests, how to use our hospital's operative system, etc. And from april to may we do a month long internship in the University Hospital. There we are divided in groups and each group goes to a different section.

Third year is even more nursing oriented, being some of the subjects English, Care and procedures on women, childhood and adolescence; Critical Care Nursing; Emergencies Nursing; OR and some others. First semester, from September to November we go to class and then November and December we do internship again in the hospital. Second semester is from February to May, we have school february and march and then to the hospital again till the end of may.

The fourth year we don't have any clasess or school but we have a year long intership in the hospital (8 to 12 hour shifts) and healthcare centers (8 hour sifhts).

Months January and June are exclusive for tests the first three years and in the last one we have to do a "TFG (Trabajo de fin de grado)", an end-of-degree project.

Our profressor are mostly male and female nurses, but we also have pharmacists, physicians, nutritionists, psychologists and psychiatrists.

Then, after you've graduated, you can either start working or do an exam called "EIR" to become an Internal Nursing Resident and do a two year specialty (being paid).

I hope this all makes sense since I'm not an english native speaker.

Suturing in 2nd year? Cooool... Have met and worked with Spanish nurses, highly skilled people! Gracias for your input [emoji8]

[walkingdeadhead]

Hello everybody!

I'm Alicia, a second year nursing student from Spain.

Since no one here has commented anything about how it is to study nursing in Spain, I'll do it.

Here, since 2009, we have a four year degree. Each year divided in two semesters.

First year is all general themed, anatomy, physics, physiology, pathology, biochemistry, nutrition, english and some more. But the last month of the schooling year we get to go to a public healthcare center. There we're only allowed to do the simple things like, take temperature, blood sugar, blood pressure, weight and measure patients, among other little things like prepare meds. Since the 120 of us go to different centers some get to do more than others, for example, I got to do home visits, do shifts in the er, do appoinments on my own and even vaccinated in adults and pediactrics, but some of my friends didn't get to do half of what I did.

Second year gets more nursing oriented. We have this subjects called "Farmacología y dietética, Enfermería Clínica, Salud Pública y Comunitaria, Gestión, Ética y Legislación Sanitaria, Psicología, Bases Teóricas y Metodológicas de la Enfermería y Prácticas Clínicas": Pharmacology and Dietetics; Clinical Nursing; Public and Community Health; Management, Ethics and Health Legislation; Psychology; Theoretical and Methodological Foundations of Nursing and Clinical Practice.

Every subject has two different parts, a theorical one and a practical one.

This second year we're taught how to suture, bandages and plasters, different examinations and tests, how to use our hospital's operative system, etc. And from april to may we do a month long internship in the University Hospital. There we are divided in groups and each group goes to a different section.

Third year is even more nursing oriented, being some of the subjects English, Care and procedures on women, childhood and adolescence; Critical Care Nursing; Emergencies Nursing; OR and some others. First semester, from September to November we go to class and then November and December we do internship again in the hospital. Second semester is from February to May, we have school february and march and then to the hospital again till the end of may.

The fourth year we don't have any clasess or school but we have a year long intership in the hospital (8 to 12 hour shifts) and healthcare centers (8 hour sifhts).

Months January and June are exclusive for tests the first three years and in the last one we have to do a "TFG (Trabajo de fin de grado)", an end-of-degree project.

Our profressor are mostly male and female nurses, but we also have pharmacists, physicians, nutritionists, psychologists and psychiatrists.

Then, after you've graduated, you can either start working or do an exam called "EIR" to become an Internal Nursing Resident and do a two year specialty (being paid).

I hope this all makes sense since I'm not an english native speaker.

Spain's way seems like a mix of the U.S. and some of the European country's described here (a lot of core/general classes and nursing classes, and a lot of time to devoted to clinical care). I would think nursing is very highly respected as a profession there. Your English by the way is awesome!

[Aliareza, BSN]

It does sound so much more complicated than it is. When giving medications this way repeatedly it goes much quicker. And it is safer for the patient.

I disagree with this entirely.

When our system goes into downtime overnight, I usually jump for joy. I get all my assessments in before the downtime starts and then all I have to do is maintain the patient. Giving AM meds during downtime is heaven. I get the MAR, circle the meds (instead of writing them on my brain sheet), pull them, double check against the MAR, and then open them all and give them to the patient (after checking identity of course). If I had to do it through the EMAR, I'd have to scan the patient, check the identity, scan each pill, enter reasons on giving a PRN, and probably enter reasons on every single drug for giving them "early".

Most of the AM drugs that night shift gives are scheduled for 7 am, and can officially start being given at 6 am. There's no way to start at 6 and give 6 patients their AM meds (you wake most of them up and they need toileting, which is a lengthy affair for post-op joint patients). I start at 5, which is accepted practice because the administration knows that we can't start at 6 and be done by 6:30-6:45 to start giving report to the day shift. Thus entering a reason for giving an early dose on every single med for most patients.

Computerized charting is faster for the daily assessment I think, but much more cumbersome for giving meds. The additional safety features make it worthwhile (I *really* like knowing I'm not going to accidentally make a med error), but soooo time consuming.

Oh, and then not having to double chart the pain assessment and reassessment for PRN pain meds is great. All I have to do is write "Pain rated at level 7, present in hip. Pt describes pain as stabbing, shooting pains. Administered 1x Norco 10." instead of going through the process of doing drop-down menus and checkboxes for every single little detail of it.

[K+MgSO4, BSN]

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.

This only works if your hospital also has either an EMR or at least an EMM. The new building at my hospital has installed Pyxis but still using a paper drug chart. This does not does not eliminate errors.

[K+MgSO4, BSN]

I did hear a rumour once about drunks who come into the ED. We used to put them on mats on the floor "out back" so they could sleep it off, but someone turned out to have an SAH and died so now they're on trollies and have hourly GCS assessments. We heard that in the US many many drunks are intubated and placed in the ICU overnight and then discharged the next day... That's not true is it?

We tube them here in Australia for about 4 hrs, leave them in ED and then when they start to sober them up extubate and send round to short stay for about 12 hrs.

Thanks irishicugal for starting this thread. I have had it on my to do list for ages and never got round to it. I was the first of the undergrad degree nurses to graduate in 06. I left Ireland in 08 for Australia. I look at my classmates, those that stayed in Ireland are still in the same job they got when they qualified, no opportunity for career progression, massive culture of tall poppy syndrome, short term solutions implemented for cost cutting but no analysis of long term benefit.

I have had opportunities to run a ward (NUM)for 18 mths, bed management and now a secondment to risk and improvement. My classmates think risk and improvement is HIQA and hand hygiene audits (lol).

Can I just correct the person who stated that 1:4 was becoming law.... it is not that simple, ratios are being mandated yes but it depends on the tier of your hospital what they will be, plus this is only in Victoria.

There is a happy medium to be obtained between the various undergraduate models described by Ireland, America and Australia - however I should be working on my uni study today not hanging out here, it is difficult to work it out, as each country needs to model it based on the needs of that country nursing and education model (but the neighbors are having a really loud party).

People who are looking at working internationally, the roadblocks with both Ireland, UK and Australia for US nurses is often undergraduate clinical hours.

[itunsco]

I am a traine nurse from Nigeria. I find my situation similar to yours. When I got into USA hospital transition was crazy, I had to go on you tube to understand stuff. I have practiced and very confident in my feild while I was in Nigeria but I lost all confidence when I got into USA hospita.

We calculate our drips and know nothing about pump, computer charting, scanning, etc

There is no LPN we only have RNs either as an associate and very few are offering BSn which really does not matter, the different was pay.

Staffing.... We call it wards. I have a whole ward of 24 patients, drag around carts pass meds to everyone as I go from bed to be, I never got burned out for once. I have a ward audley (tech) very useful and dont talk back when assigned a task, it was a blessing and a pridviledge.

Lab values are measured in different metric. Everytime I ask in USA are u sure thats a right value but measurement are different

To work in Labor and delivery in Nigeria, you have to be a Midwife..... all you need here is few weeks training before you start catching babies.

Lastly.... I have never in my lifetime seen PEOPLE take so much damn pain medicine. Dilaudid, oxy, morphine, phenegan, benadryl, PCA....all on one pt for having minor surgery..... Anyway they had to constantly remind me that pain is SUBJECTIVE. hahahaha

I Thank God for the opportunity... the pay is better that back home. God Bless America

[irishicugal]

I am a traine nurse from Nigeria. I find my situation similar to yours. When I got into USA hospital transition was crazy, I had to go on you tube to understand stuff. I have practiced and very confident in my feild while I was in Nigeria but I lost all confidence when I got into USA hospita.

We calculate our drips and know nothing about pump, computer charting, scanning, etc

There is no LPN we only have RNs either as an associate and very few are offering BSn which really does not matter, the different was pay.

Staffing.... We call it wards. I have a whole ward of 24 patients, drag around carts pass meds to everyone as I go from bed to be, I never got burned out for once. I have a ward audley (tech) very useful and dont talk back when assigned a task, it was a blessing and a pridviledge.

Lab values are measured in different metric. Everytime I ask in USA are u sure thats a right value but measurement are different

To work in Labor and delivery in Nigeria, you have to be a Midwife..... all you need here is few weeks training before you start catching babies.

Lastly.... I have never in my lifetime seen PEOPLE take so much damn pain medicine. Dilaudid, oxy, morphine, phenegan, benadryl, PCA....all on one pt for having minor surgery..... Anyway they had to constantly remind me that pain is SUBJECTIVE. hahahaha

I Thank God for the opportunity... the pay is better that back home. God Bless America

We have very few nurses from Nigeria in ireland, the qualification isn't recognised - most nurses who come here work as carers instead. But yeah, with you on the pain medicine - we rarely use narcotics, more so in the ICU, but yes, we have always been taught "pain is what the patient says it is!"

[Here.I.Stand, BSN, RN]

I'm pretty sure Irish nurses sound cooler when they talk than Midwestern American nurses do.

I learned about the no-restraints rule on here last year, when my discussion of their use got me a threat from the UK. Most nurse : pt ratios in ICUs here are 1:2, some I'm sure that has something to do with it...we physically can't be with that one pt at all times keeping him from self extubating. How deeply are ICU pts sedated? The trend here is to use less sedation than we did years ago; sometimes they aren't even on a drip, but just get prn midazolam. Of course if the pt is paralyzed or otherwise unable to grip, they aren't going to pull tubes/lines, so those ones are not restrained.

All ICUs I've been in here have electrolyte replacement protocols, so that we can order replacements without calling the MD. There are some exceptions, e.g. CrCl too low, or in the case of MgSO4 pt needs to be at least 50kg. For them if the results are low we call the MD for an individual order. We are definitely able to critically think and know what our pt needs, but as another poster said rules often prevent us from just ordering tests etc. ourselves.

I've personally never taken care of a pt who was intubated simply for being drunk. I did have one who turned out to just be drunk, but he'd had a MVC (car accident) and his behavior was suspicious for a bad TBI, followed by a failure to protect his airway. But then his scans all came back negative --he had no injuries except for a possible concussion -- so was extubated and sent home that morning.

[irishicugal]

I'm pretty sure Irish nurses sound cooler when they talk than Midwestern American nurses do.

I learned about the no-restraints rule on here last year, when my discussion of their use got me a threat from the UK. Most nurse : pt ratios in ICUs here are 1:2, some I'm sure that has something to do with it...we physically can't be with that one pt at all times keeping him from self extubating. How deeply are ICU pts sedated? The trend here is to use less sedation than we did years ago; sometimes they aren't even on a drip, but just get prn midazolam. Of course if the pt is paralyzed or otherwise unable to grip, they aren't going to pull tubes/lines, so those ones are not restrained.

All ICUs I've been in here have electrolyte replacement protocols, so that we can order replacements without calling the MD. There are some exceptions, e.g. CrCl too low, or in the case of MgSO4 pt needs to be at least 50kg. For them if the results are low we call the MD for an individual order. We are definitely able to critically think and know what our pt needs, but as another poster said rules often prevent us from just ordering tests etc. ourselves.

I've personally never taken care of a pt who was intubated simply for being drunk. I did have one who turned out to just be drunk, but he'd had a MVC (car accident) and his behavior was suspicious for a bad TBI, followed by a failure to protect his airway. But then his scans all came back negative --he had no injuries except for a possible concussion -- so was extubated and sent home that morning.

Irish accents are sexy [emoji12][emoji12] I think the main reason we're 1:1 in ICU is we've no RT's or techs, so we do everything! Also I seem to hear about patients in the ICU in the US that would be in HDU or CCU here. We tend to have level 2 as a minimum, but the majority are level 3. We are big into sedation. On initial intubation, propofol infusion, then wean to fentanyl/morphine or dexdor. Generally looking for a RASS of 1 or below. We generally wean off sedation when looking to extubate. I've seen YouTube videos of patients communicating with white boards and using bicycle arm exercisors while intubated - can't see that ever happening here! If they're awake enough to do that, they're awake enough to be on non invasive ventilation!!

In terms of tests, we send off routine labs daily or twice daily, run our own abgs and do weekly septic/mrsa screening. Basically if we think something stinks, it goes to the lab!!