Nurse education in the United States vs Ireland & UK

[Pearlite]

Hello and apologies in advance for the very long post

So I am a healthcare assistant here in Ireland and will be starting a nursing degree in September and in my great excitement am currently researching everything I can about nurse education and training. I have some questions about the (significant) differences in nurse education between the US and Ireland & the UK.

The Irish Department of Health recently published a report on undergraduate nurse education in Ireland. Nurse training in Ireland has been a four year degree since 2002 and Mids has been since 2006. In the report they looked at the current system of nurse education here which is a specialist model i.e. decide at the point of entry which discipline you will train in (general, children's & general, mental health, intellectual disability and midwifery). So in this report they looked at the US model to see if it would be better for Irish nurse training. They decided that the current model suits Irish needs best for the following reasons:

The Curriculum Subgroup identified that a generic model had deficiencies in terms of:

- a minimal focus on the clinical and theoretical aspects of the particular specialist discipline which leads graduates to be inadequately prepared to function as discipline specialists (e.g. a mental health nurse not being adequately prepared to work in community and in-patient settings)

- a requirement for post-registration programmes to develop basic competencies for population groups - difficulties with recruitment, retention and workforce planning

- loss of specialist nursing knowledge and skills in the care of clients with intellectual disabilities

- developing a professional identity.

Now, to me, the obvious disadvantage to specialist training is the lack of mobility without further costly and demanding training (a registered children's nurse post grad is 1 year full time). But I think the points the report made above are compelling. And as far as I know nurse training in Ireland has always been specialised - both my aunts are nurses; one general + mids and the other psych + children's.

So my questions for US student nurses/registered nurses:

• How do you overcome the obstacles noted by the committee (quoted above)?
  
• In your preregistration training, do you get instruction and clinical training in all the above disciplines of nursing?
  
• How do you manage to go from learning how to manage a pregnancy and deliver a baby (not 100% sure if US nurses/midwives do this going by One Born Every Minute USA?) to promoting independence in a young person with a severe intellectual disability to working in a mental health special care unit? Does it even work like this? Or are these things learned at postregistration level?
  
• Do you think you'd be better prepared to work with specialist populations if your preregistration training was specialised or would giving up the mobility associated with generic training be a non runner for you?
  

It interests me so much that while at the end of the day, nurses on both sides of the Atlantic do more or less the same thing yet training is so different! Thanks to anyone who reads that wall of text and responds

PS just wanted to add that I understand that our health and education systems are very different and together with population/cultural differences would have an impact on training methods and needs

[Esme12, ASN, BSN, RN]

The US nursing model is a generalist education. All nurses are educated in the general care of all patients in basic nursing school.

There are 3 levels of entry in to nursing in the US (I know right? )

Diploma....hospital based/supported with college for pre-reqs (chemistry/anatomy etc) only. Large amount of clinical exposure during clinicals.

ADN/ASN....community college based 2 year....(sometimes 3 if you take pre-reqs separate) much less clinical experience

BSN....4 year University based minimal clinical experience

Confusing isn't it. This qualifies you to take a licensing exam as a generalist....specialty follows later. All our midwives, clinical specialists are advance degrees.....masters levels.

I think the generalist education helps us care for the patient in a more rounded holistic fashion ...however with experience you gain this knowledge and utilize the same information when caring for patients. We utilize experience in specialty with post graduation certification and education specific to specialty to further specialize in the field of your choice.

[LadyFree28, BSN, LPN, RN]

Hi Pearlite!

Yes in the US, we are established as generalists. Our programs are designed to provide holistic care to our populations, providing our licensure to be of a generalist nature-our licensure exam-the NCLEX-provides questions that cover subjects such as Peds, Mental Health, OB, etc., however the key of becoming a licensed entry level nurse are four components: Safe, effective care; Health Promotion; Physiological Integrity; and Psychosocial Integrity. These components are transferable, regardless of specialty. For example, if a OB patient has kidney stones, depending on the trimester that the patient is in, will be on Med-Surg, but her status will be taken under consideration, same for Peds and Mental Health patients...there status doesn't change. That's where the "holistic" thinking comes in.

Upon going into a specialty area, there is on the job training and educational support for that specialty. There are hospital and health systems that design programs for the employees so that the fundamentals of what we are taught in school are built upon on the job. RNs can be specialized and become certified in a specialty after a period of time working in a specialty, so there is ample opportunity to be "specialized". Certified in a specialty constitutes a proficient, competent level in that specialty.

I highlighted your questions and decided to specifically answer them:

[*]How do you overcome the obstacles noted by the committee (quoted above)?

I don't see the "obstacles" as the committee stated as obstacles. Having a generalist training has allowed me to be able to effective care for a pt with a mental health diagnosis, a person with a intellectual disability effectively in a medical-surgical environment, and tailor teaching and interventions specifically for the individual.

[*]In your preregistration training, do you get instruction and clinical training in all the above disciplines of nursing?

Yes. We are required to have extensive hours in theory and practicum rotation in all disciplines. Students are also encouraged to seek additional exposure to specific specialties by interviewing for "nurse extern" positions. Some programs have programs specifically for student to have extra semesters totaling an additional year of clinical experience in a specialty setting. These programs either have a relationship with area programs or can be open to all. They are very competitive to get in. Not getting into one does not make or break a nurse who wants to specialize. There are opportunities to make such moves whether newly licensed or licensed over 5, 10-plus years, etc.

[*]How do you manage to go from learning how to manage a pregnancy and deliver a baby (not 100% sure if US nurses/midwives do this going by One Born Every Minute USA?) to promoting independence in a young person with a severe intellectual disability to working in a mental health special care unit? Does it even work like this? Or are these things learned at postregistration level?

Depending on the structure of the program, rotations are arranged in theory in what would be close in theory. In my program, health assessment and Maternity were in the same semester, because of the advanced assessment in maternity, it was a great transition. Some are structure with Maternity and Pediatrics in the same semester.

I had assessment and Maternity in the same semester. I assisted in giving birth with 3 mothers, 1 C-Section, had two post partum patients, and their children per clinical day, rotated in the special care (NICU) nursery and the newborn nursery. It wasn't daunting at all. The setup of Maternity was taking care of the mother and the child.

Either way, adequate theory and practicum is established. As far as intellectual disabled individuals, those factors are considered in all aspects...there is no separation of specifics...those 4 factors I spoke about in terms of licensure come up...Health Promotion is a factor to ALL, regardless of disability. It is probably due to our factor in how "health" can be determined as broad in terms of function in our society, and in theory, every individual has the chance to maximize their well being is optimal in terms of health promotion in our country.

[*]Do you think you'd be better prepared to work with specialist populations if your preregistration training was specialised or would giving up the mobility associated with generic training be a non runner for you?

For me, I do not see the chance of nursing school to be specialized, because that would drop the holistic nature in nursing, in my opinion. We encounter people with various backgrounds, cultures, abilities, etc, and for that, we tailor out interventions based on individuals. Again, no one loses their specific health issue whether I am treating them in the community or in the hospital or in a facility. The generalist role allows for that, and there are many opportunities to specialize post licensure. There are plenty of associations that assist with continuing education and support to become specialized.

[Pearlite]

Thank you both for your informative and interesting replies :) I definitely see your point about a generalist approach being more holistic. I imagine it sets you up to care for, let's say, a pregnant woman with an intellectual disability or mental health patient with lupus in a more rounded manner rather than thinking well I'm a mental health nurse so I'll just let the general nurses take care of the lupus side of things and vice versa. I hadn't thought about it that way and in that respect generalist training has a strong advantage. I imagine it makes training all the more interesting also, getting to see a bit of everything.

In some of my placements during my hca training I saw some instances where more generalist training would have been an advantage e.g. a patient with a serious mental illness on a surgical ward and the nurses didn't really know how to care for him as a whole person and his care definitely suffered because of that.

Esme12 that's quite a lot of choice when it comes to picking a route into nursing! Each of them seems to have their benefits and drawbacks. Would those routes be looked on differently by employers or would they all be seen as equal once you passed your exams and achieved your licence? Can you go straight into all of those from high school?

[HouTx, BSN, MSN, EdD]

The only way that the US generalist model has continued to be successful is by shifting actual competency development onto the organizations that employ new graduates. This has been widely documented. In our current economic climate (rapidly shrinking reimbursement for healthcare services) employers have become very reluctant to continue to support the ongoing "post graduate education" that is needed for new graduates so they are simply not hiring them.

Our 'entry into practice' debate is a long running one. Diploma programs have been largely eliminated in most areas of the nation - so the ongoing debate is currently focused on ADN vs BSN. Very large scale research studies have clearly indicated that increased numbers of BSN-prepared staff have a significantly positive impact on patient outcomes in acute care settings. Therefore, in October, 2010, Institute of Medicine recommended that acute care facilities have at least 80% BSN staff by 2020.http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Education%202010%20Brief.pdf This same ratio has been integrated into the Magnet criteria for acute care facilities espoused by professional nursing organizations. Across the US, acute care hospital systems have 'raised the bar' and restricted hiring to BSN only although this is not yet a legislative mandate. ADN nurses are still welcomed in acute care in areas that do not have sufficient numbers of BSN nurses available.

Clinical specialization in the US occurs post licensure in master's level education. Nurses can also achieve specialty certification by passing board exams. Eligibility for many specialty certifications is currently restricted to BSN nurses who have the requisite number of worked hours in the specialty area (usually 1 or two years).

And - high school graduation (or GED test indicating mastery of high school curriculum) is all of the education that is required prior to attending university or college. However (you knew this was coming - LOL), colleges require additional formal testing as part of their entrance requirements. If you do not place high enough on the test, you may have to take additional remedial-level courses in order to be eligible for general college-level courses. Prospective nursing students also have to pass additional tests to be eligible for those programs.

Confusing & expensive - that's US nursing education. It's a wonder we still have so many people clamoring for it.

[elkpark]

The only way that the US generalist model has continued to be successful is by shifting actual competency development onto the organizations that employ new graduates. This has been widely documented. In our current economic climate (rapidly shrinking reimbursement for healthcare services) employers have become very reluctant to continue to support the ongoing "post graduate education" that is needed for new graduates so they are simply not hiring them.

Given the current prevailing philosophy and approach to nursing education in the US, I don't think a specialist system like that used in the UK would necessarily turn out better prepared clinicians. We could be doing a much better job now of educating clinicians prepared to function in clinical settings upon graduation; TPTB in nursing education just choose not to.

[Esme12, ASN, BSN, RN]

Thank you both for your informative and interesting replies :) I definitely see your point about a generalist approach being more holistic. I imagine it sets you up to care for, let's say, a pregnant woman with an intellectual disability or mental health patient with lupus in a more rounded manner rather than thinking well I'm a mental health nurse so I'll just let the general nurses take care of the lupus side of things and vice versa. I hadn't thought about it that way and in that respect generalist training has a strong advantage. I imagine it makes training all the more interesting also, getting to see a bit of everything.

In some of my placements during my hca training I saw some instances where more generalist training would have been an advantage e.g. a patient with a serious mental illness on a surgical ward and the nurses didn't really know how to care for him as a whole person and his care definitely suffered because of that.

Esme12 that's quite a lot of choice when it comes to picking a route into nursing! Each of them seems to have their benefits and drawbacks. Would those routes be looked on differently by employers or would they all be seen as equal once you passed your exams and achieved your licence? Can you go straight into all of those from high school?

Yes you can enter these right out of high school....however with the poor economy the enrollment is up at nursing programs and is very competitive.....while they all take the same licensing exam....there is a push for the BSN grad as the only entry level and in most parts of the US there is a surplus of graduates and the BSN graduates are being considered before other new grads....but this is a recent development. They were once considered equal as recent as 10 years ago.

There is NO pay differential at the onset but the BSN grad will have more advancement opportunities. This is also a recent development

This happens to be a HUGE hot spot of debate right now in the US.

[nurseprnRN, BSN, RN]

Our generalist maternity rotation isn't a midwifery course, either. I remember when I worked with a UK SRN (State Registered Nurse) and she had a midwifery license as well as the adult general one. She actually got to deliver babies, whereas we would not as students, and would not be expected (or allowed) to take a midwifery job right out of school; would have to take a midwifery course after basic training for that.