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?

[K+MgSO4, BSN]

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

West coast 360 days of rain.........sunny south east is where I would go if I returned. I'm from the north west where next stop NY. However I'm happy in Melbourne :)

[Guest805836]

Hey everyone ! I'm a nurse in France, have been working since 2009.

The nursing curriculum has changed (since 2009, so I am one of the last classes of the "old" curriculum) to be in line with the Bologna accords; this has brought the studies in nursing to "licence" level (approx. bachelor, since the next degree, which takes 2 years to complete, is a master's degree, and after 3 more years, a doctorate). I wont be able to speak of the current curriculum, since I have no experience with it; I know that they added quite a bit more higher level theory and let go some of the "fluff" (thank you, higher educational powers that be)!

My studies were 3 and a half years long (start in september, end in november three years later) and there was no university degree attached, the nursing institutes were under the sole responsability of the ministry of health. Nursing studies in France are directly post baccalaureate (our 'end of high school diploma'), no pre-requisites, but there is an entry exam for the school. The exam is first written : a test which looks a bit like IQ testing with exercices to test for logic, problem solving... and a part where you have to answer open questions about social and healthcare related questions. After the written exam, those who made a pass grade go on to an oral exam, where you discuss your motivations to become a nurse, what you think the profession will entail. The purpose is mostly to filter out those who wouldn't be a good fit/ those who are crazy (doesn't always work out well, from my experience). After that, we are ranked in order of our combined written and oral examination marks, and the first N people get into the school. I was in a big hospital based institute, in a large city, we had 200-odd people in my class.

We studied by "modules", with some of them for the duration of the curriculum (legislation and health regulations, organisation of health system in France, ethics, social studies, pharmacology...), and the others were oriented to medical and surgical specialties. For instance, in the 1st year we started with cardiology, ortho and traumatology, geriatrics, endocrinology.. For each module we would start with the pertinent anatomy and physiology, review the most frequent pathologies and physio-pathological processes, the treatments, the pharmacology, the diagnostics tests... We also had smaller study groups to practice some technical gestures (blood drawing on a fake silicone arm, anyone?) and working on/analysing clinical situations (creating a care plan, therapeutic education, communication techniques).

A lot of time was also devoted to clinical rotations. Typically a school year would be one month of studying (usually two modules at the same time, plus the general ones) followed by an exam, and one month of clinical rotation (140 hrs). We had 5 placements per year, and it was mandatory by the end of our studies to have been in at least two medical units, two surgical units, two psychiatric units, two 'elderly care' units and two 'social care/public health' places. Besides that, there was an obligatory 'operating room/acute care/ER' (whichever one) clinical and a pediatric or pedo-psychiatric clinical. In the second year and third year, the clinical rotation in the summer was two months long and was an elective (we got to choose the place, as long as it was possibile for the place to recieve us and if it was within the parameters of the clinical rotations we had to do).

So in first year, 700 hrs clinical rotations, 840 hrs second year, and 980 the last year (the last clinical rotation we had a practical examination which was half of the validation of the diploma).

The students are precepted by the nursing staff on the unit. Usually in the 1st year we shadow the nurses aides a lot, but once the basics of adl are okay, we shadow the nurses. Unfortunately, there isn't a universally accepted system of precepting students, so depending on the unit culture/wishes of the team, we don't have the right to do the same things. At the end of the first year, I had the luck of being in a pneumology oncology unit, and the nurse who precepted me was big on having a comprehensive view of nursing work, so I was in charge of two patients (with her supervising everything), and I got to hang chemotherapy, blood, antibiotics, do dressings, access ports... At the end of first year, we are supposed to be able to take care of two patients, 2nd year 4 patients and last year 6 patients (loosely supervised by the nurse, but by the end, I was more or less flying solo, just asking for her opinion and confirmation). As far a I recall, there were no procedures I wasn't allowed to do, as long as I had proper training and supervision by a nurse.

As far as work goes, as I had done a two month clinical rotation at my first place of work as a student, I had a fairly short orientation (three weeks). Most new nurses don't get much longer, but the studies are very hands on and I feel that I was well prepared to take on my work. The ratios in the units are high compared to what I've seen mentioned here for the US : I was in a busy surgical floor (heart and vascular surgery, so quite a few patients on telemetry surveillance) and I had 7 to 11 patients to myself, with a nurses aide.

The nurses aide is a profession which has no personal scope of practice, we are allowed to delegate non invasive procedures (basically, adls and non critical vitals). They do not access IVs, put in Foleys, do any dressings... Technically, they do not have the right to give medication even orally, although exceptions are made in certain settings (for example, in a retirement home, where you can sometimes have 2-3 nurses for 80 residents!).

Nursing scope of practice is very well defined, there is a set of laws which describes which procedures are our prerogative and on which we are fully autonomous (usually stuff pertaining adls, assessment of patient status, surveillance of medical equipment, therapeutic education...); a list of procedures we are allowed to do with a doctor's order (IV, blood draw, putting in a foley or a NG...), a list of procedures we do with a doctor's order under the condition that the physician be able to intervene at all times (blood transfusion, defibrillating on manual mode, vaccinations...) and a third list of procedures in which we can assist the physician (so he has to be present the whole time), like helping with the putting in of central lines, doing ECGs with cardiac modifiers, etc.

Doctors are usually not very proficient at most of these technical tasks, which they never practice routinely (aside from anesthesiologists, who are life-savers for putting in difficult IVs), plus, they are severely understaffed and overworked.

I now work in a cardiac ICU, where we have MI patients, acute arrythmias, chronic or acute heart failure... If the patients are vented, we have a ratio of maximum (hold your hats, I know for those of you on the other side of the pond this is shocking) 3 patients per nurse, if not vented, 5 for one nurse. We also have one nurses aide per nurse (less during the night). From reading this forum, I get the feeling that we do less turning and repositioning of our patients (certainly not once every two hours, I wouldn't be doing anything else otherwise!), and less frequent mouthcare. I feel sort of inadequate when I read the ICU forum here ^^ However, I work in one of the top hospitals in the country, and we have good patient outcomes more often than not ^^ despite our suboptimal mouthcare regime.

There is a number of nursing specialties possible after the licence. First, pediatric nursing, it is a one year long program. It is not an obligation for work in pediatrics, but it is a plus (especially since it is difficult in my city to get hired in pediatrics, so this is the best way to do so. This program can be done immediately post-nursing school.

Second, there are OR nurses, this program is 18 months long, and you have to have two years of previous experience in the OR (so it isn't an obligation for work in the OR as well).

Thirdly, there is anesthesia, this is a two year program, you have to have two years previous experience in ER or ICU. (I just got accepted into this program, I'm going back to school in october!!!)

Fourth and last, "head nurse" school, which is the program both for those who want to become educators and those who want to work in administration; it is one year long and you need 4 years of previous experience and to show your involvement in a unit project.

All of the nursing specialties have entry exams and are considered post-secondary education, so not free; however, most work places will finance their agents (pay the school and pay you your salary for the duration) in return for a contract with them after the studies are completed (three years owed for one year paid, with a maximum of 5 years owed to the workplace).

Voilà :)

[joanna73, BSN, RN]

Registered nurses who didn't have degrees, diploma nurses and enrolled nurses could just top up their qualifications to degree level. There was/is no obligation to do so, but it's unlikely you will ever be able to move up the management/clinical ladder without a degree. There are a lot of nurses who chose not to top up and can not move from their band 6 staff nurse positions.

Similar for Canadian nurses. The four year degree was mandated for all new grads from 2004-2007, depending on the Province. The 2 year diploma program has been phased out for all RNs.

However, diploma RNs were basically grandfathered in. That said, anyone seeking advanced practice roles or management roles without a degree are limited, and now a Master's degree is becoming the entry point for these roles.

[RN-IDE]

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?

Hello.

I am surprised that there are not more posts from European-trained nurses on this site.

I was trained in France. I met an RN CCRN from Swiss here and his experiences sounded similar.

To reply first to your questions,

1/ They are trained within and many go back to school for a one year+ intensive.

2/ Yes, nurses are in operating rooms and there is a 2 year additional course sequence to follow if one wishes to obtain official operating nurse recognition. However, IBODEs (the cert) are scarce. Hence, many times hospitals will train within.

3/ "Liberal" nurses in France must have minimum two years' experience prior to requesting their registration as such. They alternate home visits and office hours. They usually sign onto a shared Liberal Nurse office before becoming independent.

Home health (case workers) organized through hospitals is a different scenario (internal hire).

Liberal nurses exist as home visits by doctors and psychiatrists exist in France.

4/ In France at least the pay may be lower, however the overall spending capacity is much higher. The property tax is roughly 0.1%, income tax (contrary to popular belief in the US) is much lower, healthcare is 70% covered (the remaining 30% by private supplemental insurance usually offered by employers or if one has a chronic illness as classified and validated through two independent physicians public health coverage is available), health costs lower even if paid out of pocket, cell phone service is lower, as are utilities, sports and activities for children costs less, etc. I find in France the basics are far less expensive than in the US and there are no hidden surprises. Luxury items (BMW or an iPhone) might cost more.

In basic schooling French nursing students run a full time schedule and alternate theory with clinical (one-two moths, then one to two months). We complete nursing school with 2040 hours of clinical experience and we are required to take patients in charge from A to Z. Clinicals ressemble me proctorships from 2nd year onwards. Finally out research must be a combination of evidence based practice review and original research. We are required to establish methods and fieldwork both quantitative and qualitative. The research preparation takes nearly two years and culminates in presentation to jury.

When we are hired out of nursing school (usually through our internship) we are followed closely by a proctor for three months before full status is accorded.

[RN-IDE]

Oh hello! I was trained in France as well.

[Guest805836]

Hey to fellow French colleague :) what area are you based in ?

I have left the bedside and I'm in my first semester for my anaesthesia speciality ! Tough but really interesting.

[RN-IDE]

I worked in the ICU in France for a short period and was offered a job with the SAMU. However I moved to US (California) for family reasons.

The administration here has been amazingly frustrating. Three lost files, all to conclude in four full copies and an immediate okay. Many State Boards have encountered restructuring in recent years, so I believe much was due to that.

I'm working two PT jobs:

independent contractor for events as either nurse or medic (sporting, business, tv and film prod), and

school nurse

...while now battling with school administrations. I am pursuing end goal nurse practitioner.

:)

I have met other RNs that were schooled in Europe (Switzerland- CCRN, Poland- Labor & Delivery, Netherlands- FNP) who are all successful today yet who also lived through h---.

The Swiss nurse seemed to have the most similar schooling to France (and their nursing transcript and files were the same). He kept telling me to not worry about the NCLEX. I did not buy the "it was easy." I lived through my preparation in tears and a panic, all to discover it wasn't that bad for someone experienced and schooled abroad. If I recall well enough the NCLEX is waived if a foreign schooled nurse had already worked for 5 years or more.

While waiting for the administration to pull through I asked one BSN program (a reputable one) if I could access a clinical placement through guest status. They were kind enough to allow me to do this yet asked that I take a theory course with it. I was placed with third year students. I was able to ask about their program and view firsthand what their clinical might be like in basic schooling. From what I understand clinical management varies from school to school. In the case of this program there were relatively few hours (and only a few hours of class per week). The students were accorded little autonomy other than for nursing assistant roles. I believe that legal fears might play a role in this.

I did note that the RNs in ICU took a larger officialize role in medical rounds. Rather than impromptu transmissions, they presented cases to seated medical staff.

Nursing education here is so varied amongst schools it may be the origin of distrust of foreign diplomas both administratively, by employers and schools. Luckily I have a Masters in another subject and a degree that is from the US. If I had not, I might be faced with repeating years of studies. I might have to repeat research, leadership and community nursing. I begin to complete "undergrad" starting 2017.

So I have just been working on cleaning up my records so they can align with what school administrative checklists required. I wish that I had known and realized this long ago. I would have just bypassed the entire procedure, forgotten about my RN, and applied to a Masters Entry program.

I had wished to follow the classic route of RN, a few years experience in US, then application to MSN. Yet... US Nurse "reentry" candidates with years of experience have great difficulty finding employment. I am unsure why. If I was an employer I would much rather hire a nurse with 8 years experience to an entry position than a nurse who has no experience yet has just come out of school. There must be some legal reason behind that. Perhaps hospital insurance companies place this mandate on hospitals. Who knows. It does not take long for an experienced nurse to learn a new charting system or structure. Any experienced (non reentry) nurse would have to learn that if they changed hospital systems or focus of specialty.

I once considered moving to Texas. I believe they have the best system available for foreign nurses. Foreign nurses must complete a 6 month internship after succeeding the NCLEX. In my view this is a good idea for introduction to the system here (through the clinical I did to place heavy emphasis on charting.. yet interestingly enough the charting is also much more based on drop down menus that written text). The Texas system is also good because it probably reassures employers AND provides an opportunity for foot-in-the-door hiring process. If anything the foreign nurse would have access to previous employer letter of recommendation, which is like gold here.

Are you a student in France or here? The NP I met from the Netherlands graduated from Georgetown in MSN-FNP. Her comment made me laugh: "they were so mean to me at first.. " yet her story also provided me with encouragement: "It is worth it.. I lived through years of frustration but I did it."

I know that I will get there. The question is, will the process now take me three years or four? I shall see. I have just chosen to tell myself that it will only help to reinforce my acquired knowledge by repeating certain subjects... especially in the case of FNP.

Congrats on anesthesia btw! That is an awesome job. I remember my night shift OR experiences in basic nursing school. Amongst them I recall the Dr Anaesthesist standing with a steth chatting throughout the hours while the nurse anesthetist was doing all from A to Z He was incredibly good, especially when there was an unforeseen emergency. I also thank the anesthetist nurses for grinding me to a pulp during my internship with SAMU. Between calls they'd grill me on meds and physiology. When I was able to reply 100% they then demanded that I modify my replies to the highest level of scientific vocabulary and explanation. At the end of the internship they lauded me. If they had shown any sign of kindness or slack prior I would have never advanced during the internship as much as I had! Awesome field and career!

[Guest805836]

Are you a student in France or here?

I'm still back on Europe and have very little interest in moving to the USA. I lived there in my childhood and my mother did her nursing studies there, but I've been in France for a while now and I love my city :) but this forum is very interesting, love the nursing discussions.

Wishing you the best of luck in your NP studies, it sounds like it won't be a piece of cake but it should be worth it in the end !

I hope nursing evolves into more autonomous provider areas here, there is a projected medical shortage in the years to come, and I think the government will have no choice but to move with the times. There is a powerful medical order, which pulls much weight, so it's an uphill battle. Anaesthesia is one of the areas with the most autonomous role, but even so, there are a number of limitations, which are a bit frustrating.

[RN-IDE]

From what I read/ heard in France, the Generalists (Primary Care Physicians) blocked Bernard Kouchner's attempts to open the nursing profession wider. It too all he could take to allow Liberal nurses right to provide vaccinations independently.

I was born in the US and spent my childhood here, then lived in France for 20 years.

I miss it incredibly.

I have seen comments on lower salaries in France. Trust me, in many ways it can be far more expensive to live in the US !!!!! The taxes also pull the salaries down to closer proximity to French salaries. I see my former classmates travelling the world (even Asia) once or twice a year and think about the higher spending power in the end. It is just easier to budget as well (you pretty much know in France how much base necessities will cost each month). Perhaps I am still adjusting, yet I keep getting surprised with hidden taxes or costs through small writing.

Thank you for the good luck ! If I got through that long with the BON due to lost files I can get through this now.

Good luck to you too, you are almost there :) How exciting !!!