Differences in US nursing vs the rest of the world

Here.I.Stand, BSN, RN · Apr 12, 2016

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!!

Haha, I used to say I was going to marry an Irish guy so I could hear the accent whispering sweet nothings in my ear. I married a Korean guy...he's handsome, but not what I'd call a sexy accent. :roflmao:

But back on topic....

Bolded part -- is that 2-3 on an acuity scale? Where I work 4 is "ICU" (your standard vented pt on vasoactive drips, etc) and 5 is "critical ICU" (on ECMO, CRRT, very unstable ARDS pt being proned, pre-op organ donors erc.)

Most of my ICU's pts are 4-5, although we get stabler pts in certain circumstances:

1) they just received tPA for a stroke, and need those q 15 min --> q 30 min neuro checks that even the stepdown nurses just don't have time to safely do, 2) they are rock stable but trached on a vent -- either vent dependant at home, or haven't been able to wean off the vent. Stepdown units/floors can take pts with traches, but most don't take them if on the vent. 3) the floors are jam packed and we can't transfer our stable ones out. Also, lately we've had more surgeons just wanting their pts in the ICU because staffing on the floors is abysmal. Our charge nurses have been fighting that though -- we have a finite number of beds for critical admissions. We're a level 1 trauma center, so nearly all of our SICU admissions are unplanned.

Also, the US is a big country with diverse geography. Some hospitals are very urban, some are very rural ("critical access") and everything in between. Someone in a smaller hospital in the middle of nowhere, with fewer resources and a helicopter ride to a higher level of care, might be triaged as more critical than one who is in a university hospital floor or stepdown unit with more help at the ready.

irishicugal · Apr 13, 2016

Haha, I used to say I was going to marry an Irish guy so I could hear the accent whispering sweet nothings in my ear. I married a Korean guy...he's handsome, but not what I'd call a sexy accent.
But back on topic....
Bolded part -- is that 2-3 on an acuity scale? Where I work 4 is "ICU" (your standard vented pt on vasoactive drips, etc) and 5 is "critical ICU" (on ECMO, CRRT, very unstable ARDS pt being proned, pre-op organ donors erc.)
Most of my ICU's pts are 4-5, although we get stabler pts in certain circumstances:
1) they just received tPA for a stroke, and need those q 15 min --> q 30 min neuro checks that even the stepdown nurses just don't have time to safely do, 2) they are rock stable but trached on a vent -- either vent dependant at home, or haven't been able to wean off the vent. Stepdown units/floors can take pts with traches, but most don't take them if on the vent. 3) the floors are jam packed and we can't transfer our stable ones out. Also, lately we've had more surgeons just wanting their pts in the ICU because staffing on the floors is abysmal. Our charge nurses have been fighting that though -- we have a finite number of beds for critical admissions. We're a level 1 trauma center, so nearly all of our SICU admissions are unplanned.
Also, the US is a big country with diverse geography. Some hospitals are very urban, some are very rural ("critical access") and everything in between. Someone in a smaller hospital in the middle of nowhere, with fewer resources and a helicopter ride to a higher level of care, might be triaged as more critical than one who is in a university hospital floor or stepdown unit with more help at the ready.

Oh sorry, yes I didn't realise levels would also be different. Level 1 is wardable, level 2 is single organ failure, or inotropes, arts and cvcs etc. Level 3 is multiple organ failure, and vented. We don't go any higher. Level 2 can go to step down (HDU or CCU) but most ICU patients are level 3. I think the UK has the same model [emoji12]

mtmt99 · Apr 16, 2016

Wow! It sounds like you are extremely well trained, but seriously overworked. Thanks for sharing this with us.

Penelope_Pitstop, BSN, RN · Apr 17, 2016

This is partially off-topic (but if you've read any of my posts I doubt this shocks you) but where in Ireland are you, if you don't mind my asking?

I'm trying to formulate my plan for new residence if He Who Shall Not Be Named wins the presidency.

I think I'd like to live in Galway, based on my travels there, but I'm not sure what the work outlook is there. :)

notnursezelda · Apr 18, 2016

I know in some parts of South Asia, Pakistan/India, nursing isn't exactly as it is in the states. Most often there is a lack of support for women to go into this profession - mainly because it's considered a "lowly" job, its not considered a profession at all. Women there are mainly encouraged to go into more prestigious majors, there is a huge stigma with nursing. There are far less male nurses also. There is a huge nursing shortage there, the nurses that are there are poorly paid, but that's just the economy in those areas, mostly everyone struggles.

I just thought it was an interesting contrast, cause here in the US it's considered such a trustworthy profession, and even in nearby countries such as the Phillipines, its considered a noble calling, but not in South Asian countries.

lifelearningrn, BSN, RN · Apr 18, 2016

I would object to the use of the word "ration" with respect to socialized medicine (and I use that term loosely, because systems vary and not all universal systems are government owned). Care is rationed all the time by private insurance companies in the US with profit being a motive not triage of health conditions the way it is in other countries.

Thank you for saying this.. in the UK, healthcare is given to those in need, in America, it's given to those with the means to purchase it.

qaz99 · Apr 18, 2016

I know in some parts of South Asia, Pakistan/India, nursing isn't exactly as it is in the states. Most often there is a lack of support for women to go into this profession - mainly because it's considered a "lowly" job, its not considered a profession at all.

I think it's the same in Germany. Nursing isn't regulated and you don't go to Uni to become one. My ex German bf held little respect for nurses, funny how he understands nothing about what we do as nurses yet thinks he can make bold statements about how 'easy' our job is and how it's pretty much the doctor he trusts. Researched German nurses a bit on the Internet and yeah, seems to be a low profession over there.

NutmeggeRN, BSN · Apr 18, 2016

That's it. I'm moving to Ireland. I've done 13 patients at night before, psh, I can handle the ratios. I'm of Irish descent and my maiden name is shockingly Irish. I have freckles and love Guinness.
Where do I sign?

You are So not leaving without me!!! I say the West Coast, it is simply stunning there!!

macawake, MSN · Apr 18, 2016

I haven't read all posts in this thread yet, but what I've read so far has been interesting :)

Well, I'm a Swedish registered nurse.

Since 1993 a Bachelor's degree is the entry level for nursing practice in Sweden. Before that (from 1977-1992) nurses had to complete a three year long education but research methodology wasn't part of the curriculum and no degree was awarded at the end but you could apply for a nursing license upon completion of the studies.

Classes are all directly nursing related, hardly any "fluff". There are no accelerated programs. No matter how many previous undergraduate or graduate degrees one would happen to have, one still has to complete all the courses. (With very few exceptions. One would be a physician who decided to study for a BSN, not that I find that scenario likely to happen).

There is no absolute required amount of clinical hours, but most universities have approximately 1/4 to 1/3 of the total hours devoted to clinical placements. Im my case I had somewhere between 1,600 and 1,700 hours of clinicals.

Swedish nurses are generalists. L & D and pediatric clinical placements (and the relevant theoretical studies) are required.

There are certain areas where a new grad can not work since working in some specialties require a Master's degree in Nursing (in the relevant specialty).

Master's degrees can be obtained in the following areas:

Intensive Care, Anesthesia, OR nursing, Prehospital, Acute Care (ER/trauma), Pediatrics, Geriatrics, Psychiatry, District Nurse, Oncology, Medical Care and Surgical Care. A BSN nurse can also continue her or his education and become a nurse midwife.

The first four that I listed and the nurse midwife license are absolute requirements to work in the respective areas, in the other specialties a Master's degree is preferred but not mandatory. Most universities require two years nursing experience at the BSN level before being eligible to apply for a Master's program. When you've completed the your Master's degree you apply for the title "nurse specialist" or rather specialistsjukskÃ¶terska

At the moment only one of the two crew members on an ambulance is required to be a Master's prepared nurse (prehospital) but the trend is towards requiring that both have that education.

For my BSN I had clinical placements in many different areas. LTC, various med-surg floors, ER, OR, anesthesia, ICU, L&D, ambulance, pediatrics, psychiatry and health clinic/primary care.

Clinical placements were anything from short ones of two weeks to eight consecutive weeks. Each week being either 32 or 40 hours (four or five eight-hour shifts).

We have clinical instructors (teachers from the university) but their role is basically to coordinate and participate in evaluations with your preceptor. They wouldn't be on-site for most of the time but available by phone/e-mail if students had something they needed to discuss (or if the preceptor had questions or concerns) and would schedule evaluations typically halfway and at the end of each placement (the longer ones). At these evaulations each student would sit down with their clinical instructor and preceptor.

The preceptor is a staff nurse on the floor/clinic where the student is placed. The student wears hospital clothes (not special student/school attire) but instead of a hospital name and ID badge you wear one with your name, the title student nurse and the school's name.

The very first clinical placement usually entails a lot of shadowing "your" nurse and helping (or rather slowing down ), mostly with ADLs. You gradually take on more and more responsibility and the last year you usually carry most or the whole patient load and are expected to prepare and administer all medications, perform necessary treatments and interventions, plan the workday and delegate to CNAs, chart and give report to the oncoming nurse at the end of shift and give report to physicians if you find it necessary to alert them about a change in your patient's status/want additional orders. All this under the supervision of your preceptor of course.

CNAs usually have completed a two-year vocational training. They have primary responsiblity for ADLs, can do blood draws for labs, glucose checks and basic wound care. They can't administer any meds at all. They usually have a salary that is about 80% of a nurse's salary.

We don't have phlebotomists or respiratory therapists. Those are nursing responsibilities.

Upon graduation a nurse is expected to know skills such as blood draws, placing peripheral intravenous catheters, placing urinary catheters (both genders) and placing NG tubes. A graduate nurse is expected to be able to give pretty much all IV medications (A few exceptions require further training/education. For example chemotherapy drugs that are usually adminsitered by an oncology nurse or paralytics and anesthesia meds which will only only be given in the OR/ICU type setting).

Other skills such as inserting PICC-lines or doing arterial sticks can be taught after graduation on the floor if this is a skill that's required.

Something that Swedish student nurses don't do as a part of their training is to listen to heart and lung sounds. Bowel sounds on the other hand seems to be the nurse's domain :lol2: I think that's simply old tradition and I expect that it will change in the future. I know that I made it a priority to figure out what abnormal lungs sound like. It seemed like a useful thing to be able to recognize :)

Nurse-patient ratio on a typical med-surg floor is usually 1:4-5 or sometimes 6 during day shift and 1:6-9 during night shift. Usually there are the same numbers of CNAs as nurses assigned so you will often have "your own" CNA assigned to you for the shift. As the acuity goes up the ratios are (thankfully) better. ICU is 1:1 or 1:2.

We try to let our patients sleep during night shift whenever possible. We won't schedule for example blood draws before 6 am unless absolutely necessary and many blood draws are scheduled for 8 am. Same with meds. Of course if the patient needs meds for example every four hours or have their vitals checked often we'll wake them up, but we try to avoid it.

Unlike the US night shift is usually staffed almost exclusively by senior/experienced nurses. New grads usually starts working days or days/eves. The rationale is that there are more physicians, more support staff and more nurses around during the day shift and it's considered more suitable for the new/recent graduate.

Orientation on a hospital floor for a new grad is typically rather short; four to six weeks.

Many nurses are leaving bedside because ratios have progressively gotten worse at the same time that acuity seems to be rising. Some floors are well staffed but others struggle with retaining their nurses and depend on agency nurses to keep the floor adequately staffed.

Charting is all computerized and and most hospital floors use Pyxis/Omnicells for meds.

Medications, treatments or inteventions aren't chargeable so that cuts down on the administration involved and likely save us a lot of time. (A patient is charged approximately $10 (depending on the exchange rate) per 24-hour period hospital stay regardless of what meds or treatments are given. (The bill is sent home after the patient is discharged).

I've probably forgotten a bunch of stuff but I'm so tired after a loooong day at work that I really can't think straight :dead:

Again, thanks for an interesting thread!

Mommavik, ADN · Apr 19, 2016

I never wanted to move up to administration so never went back for my BSN

irishicugal · Apr 19, 2016

I haven't read all posts in this thread yet, but what I've read so far has been interesting :)
Well, I'm a Swedish registered nurse.
Since 1993 a Bachelor's degree is the entry level for nursing practice in Sweden. Before that (from 1977-1992) nurses had to complete a three year long education but research methodology wasn't part of the curriculum and no degree was awarded at the end but you could apply for a nursing license upon completion of the studies.
Classes are all directly nursing related, hardly any "fluff". There are no accelerated programs. No matter how many previous undergraduate or graduate degrees one would happen to have, one still has to complete all the courses. (With very few exceptions. One would be a physician who decided to study for a BSN, not that I find that scenario likely to happen).
There is no absolute required amount of clinical hours, but most universities have approximately 1/4 to 1/3 of the total hours devoted to clinical placements. Im my case I had somewhere between 1,600 and 1,700 hours of clinicals.
Swedish nurses are generalists. L & D and pediatric clinical placements (and the relevant theoretical studies) are required.
There are certain areas where a new grad can not work since working in some specialties require a Master's degree in Nursing (in the relevant specialty).
Master's degrees can be obtained in the following areas:
Intensive Care, Anesthesia, OR nursing, Prehospital, Acute Care (ER/trauma), Pediatrics, Geriatrics, Psychiatry, District Nurse, Oncology, Medical Care and Surgical Care. A BSN nurse can also continue her or his education and become a nurse midwife.
The first four that I listed and the nurse midwife license are absolute requirements to work in the respective areas, in the other specialties a Master's degree is preferred but not mandatory. Most universities require two years nursing experience at the BSN level before being eligible to apply for a Master's program. When you've completed the your Master's degree you apply for the title "nurse specialist" or rather specialistsjukskÃ¶terska
At the moment only one of the two crew members on an ambulance is required to be a Master's prepared nurse (prehospital) but the trend is towards requiring that both have that education.
For my BSN I had clinical placements in many different areas. LTC, various med-surg floors, ER, OR, anesthesia, ICU, L&D, ambulance, pediatrics, psychiatry and health clinic/primary care.
Clinical placements were anything from short ones of two weeks to eight consecutive weeks. Each week being either 32 or 40 hours (four or five eight-hour shifts).
We have clinical instructors (teachers from the university) but their role is basically to coordinate and participate in evaluations with your preceptor. They wouldn't be on-site for most of the time but available by phone/e-mail if students had something they needed to discuss (or if the preceptor had questions or concerns) and would schedule evaluations typically halfway and at the end of each placement (the longer ones). At these evaulations each student would sit down with their clinical instructor and preceptor.
The preceptor is a staff nurse on the floor/clinic where the student is placed. The student wears hospital clothes (not special student/school attire) but instead of a hospital name and ID badge you wear one with your name, the title student nurse and the school's name.
The very first clinical placement usually entails a lot of shadowing "your" nurse and helping (or rather slowing down ), mostly with ADLs. You gradually take on more and more responsibility and the last year you usually carry most or the whole patient load and are expected to prepare and administer all medications, perform necessary treatments and interventions, plan the workday and delegate to CNAs, chart and give report to the oncoming nurse at the end of shift and give report to physicians if you find it necessary to alert them about a change in your patient's status/want additional orders. All this under the supervision of your preceptor of course.
CNAs usually have completed a two-year vocational training. They have primary responsiblity for ADLs, can do blood draws for labs, glucose checks and basic wound care. They can't administer any meds at all. They usually have a salary that is about 80% of a nurse's salary.
We don't have phlebotomists or respiratory therapists. Those are nursing responsibilities.
Upon graduation a nurse is expected to know skills such as blood draws, placing peripheral intravenous catheters, placing urinary catheters (both genders) and placing NG tubes. A graduate nurse is expected to be able to give pretty much all IV medications (A few exceptions require further training/education. For example chemotherapy drugs that are usually adminsitered by an oncology nurse or paralytics and anesthesia meds which will only only be given in the OR/ICU type setting).
Other skills such as inserting PICC-lines or doing arterial sticks can be taught after graduation on the floor if this is a skill that's required.
Something that Swedish student nurses don't do as a part of their training is to listen to heart and lung sounds. Bowel sounds on the other hand seems to be the nurse's domain I think that's simply old tradition and I expect that it will change in the future. I know that I made it a priority to figure out what abnormal lungs sound like. It seemed like a useful thing to be able to recognize :)
Nurse-patient ratio on a typical med-surg floor is usually 1:4-5 or sometimes 6 during day shift and 1:6-9 during night shift. Usually there are the same numbers of CNAs as nurses assigned so you will often have "your own" CNA assigned to you for the shift. As the acuity goes up the ratios are (thankfully) better. ICU is 1:1 or 1:2.
We try to let our patients sleep during night shift whenever possible. We won't schedule for example blood draws before 6 am unless absolutely necessary and many blood draws are scheduled for 8 am. Same with meds. Of course if the patient needs meds for example every four hours or have their vitals checked often we'll wake them up, but we try to avoid it.
Unlike the US night shift is usually staffed almost exclusively by senior/experienced nurses. New grads usually starts working days or days/eves. The rationale is that there are more physicians, more support staff and more nurses around during the day shift and it's considered more suitable for the new/recent graduate.
Orientation on a hospital floor for a new grad is typically rather short; four to six weeks.
Many nurses are leaving bedside because ratios have progressively gotten worse at the same time that acuity seems to be rising. Some floors are well staffed but others struggle with retaining their nurses and depend on agency nurses to keep the floor adequately staffed.
Charting is all computerized and and most hospital floors use Pyxis/Omnicells for meds.
Medications, treatments or inteventions aren't chargeable so that cuts down on the administration involved and likely save us a lot of time. (A patient is charged approximately $10 (depending on the exchange rate) per 24-hour period hospital stay regardless of what meds or treatments are given. (The bill is sent home after the patient is discharged).
I've probably forgotten a bunch of stuff but I'm so tired after a loooong day at work that I really can't think straight
Again, thanks for an interesting thread!

Wow that's really interesting! We've sent quite a few students to Sweden to do placements, they all come back raving about it. Tell me, is your education in English, like they do in the Philippines, or are you taught through Swedish? Every Swedish person I've met has AMAZING English lol

irishicugal · Apr 19, 2016

This is partially off-topic (but if you've read any of my posts I doubt this shocks you) but where in Ireland are you, if you don't mind my asking?
I'm trying to formulate my plan for new residence if He Who Shall Not Be Named wins the presidency.
I think I'd like to live in Galway, based on my travels there, but I'm not sure what the work outlook is there. :)

Lol, I'd rather not say, we're a very small country after all!!

Seriously though, if you want to come to ireland, contact the NMBI, cos they are sloooooow.

Then once you have your licence, there are 3 types of place you can work:

1) the HSE (health services executive) run all the public hospitals. Government run, crappy pay, crappy conditions for patients and staff but it's our national health service so we suck it up for some reason.

2) Dublin Area Teaching Hospitals are our national referral centres for certain conditions (transplants, neurotic surgery etc) these are voluntary hospitals but the pay is in line with the HSE. If you want to work major trauma or cardiac surgery you work here.

3) Private healthcare. We have an increasing number of private hospitals opening here, they used to be very much just for elective surgery but many are now running ED's. Private hospitals use the US model. Ratios are less, your patients are more stable, BUT, there's no docs running around to chart stuff for you and you can feel kind of isolated. Pay is actually slightly less than HSE but benefits are much greater.

There's a lovely private hospital in Galway, I'm sure you'd love it [emoji12]