1. Boyd, Donna BSN, RN
  2. Dancer, Sandy MS, RN, ANP-C

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INTERNATIONAL NURSING allows nurses to experience a different culture of practice, to appreciate the variations in healthcare among countries, and to learn from each other. In this question-and-answer account, American nurse Donna Boyd shares her experience working as a nurse in the United Kingdom.

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Tell us about your nursing background.

After working for an airline for 20 years, I received my ADN in 1998 and my BSN in 2004. I spent 5 years caring for patients who had mainly gastrointestinal and orthopedic problems, before moving to my current position at Providence Portland Medical Center. In 6 years there, I've been providing acute care for patients with neurologic problems, including those who've had a laminectomy, craniotomy, stroke, or seizures.


What made you decide to try a nursing position outside the United States?

I've always enjoyed travel, and my family enjoys experiencing other cultures. I've bicycled in China, traveled independently by bus across the Rift Valley of Africa, and most recently journeyed into Gaza, but I've always wanted to take travel to another dimension. I wanted to be immersed in the culture, and nursing allows this. My personal life finally allowed me to make this journey: my daughters were in college, my husband was supportive, and my employer gave me a 6-month leave for my adventure.


How did you pick a location for nursing abroad?

Because communication is key, I considered countries where I'd be able speak and understand the language and then selected the U.K. This location would also give me access to the rich cultural experience that I was seeking.


How did you go about getting this job?

I began my research online. Before I could apply for licensure, I first had to prove I could read, write, and speak English by taking a 4-hour International English Language Testing System (IELTS) exam.1 Then I had to gather copies of my birth certificate, passport, marriage certificate, current nursing license, school transcripts (which had to be converted from credits into hours), and three letters of reference. All of these documents had to be notarized. Once this information was reviewed, I was cleared to take a 20-day overseas nursing course and test through the University of Bournemouth.2 Instructors from Bournemouth came to London to conduct the course because it was a more centralized location.


The program required in-person attendance for the first 3 days. I then had to complete a workbook by researching various aspects of nursing in the U.K. on the Internet, which I could do at home in the U.S. At the end of the program, I took a test in the U.K.


During my second trip to the U.K., a recruiter set me up with two interviews. Back at home, I received an e-mail offering me a position at a hospital of neurology that was permitted to bring in nurses on work visas because of significant nursing needs. I then started the visa process, which included a criminal background check and a bio/identity check (fingerprints and a digital photo). I was again thankful for the Internet, as most of this was done online. This entire process took approximately 8 months.


What sort of healthcare coverage was offered?

The U.K.'s national healthcare coverage was available to me. An individual or employer can also purchase private insurance to cover additional costs not covered by the national plan.


What sort of orientation did you get?

I received several workbooks to complete independently, including ones on medication, patient-controlled analgesia, and I.V. medication administration. Before I could perform these skills without supervision, I'd need to pass a written, oral, and demonstration test for each category. Because I'm a very experienced nurse as well as a clinical instructor, working with constant supervision was challenging for me.


I realized that I needed to get the workbooks done as soon as possible. I completed the medication workbook and submitted it, but I had to submit it two more times before it was finally signed off. The workbook was very thorough, and even when I thought I'd completed it, I'd discover I'd missed details, such as showing my mathematical calculations. This took about 3 weeks because the educator wasn't always available. I learned that most new nurses take months to have their workbooks signed off.


All departments had 2 days of new employee orientation. This included infection control, hand hygiene, equipment operation, and cultural diversity education. It also included one of the best fire safety staff development programs I've ever attended.


What did you wear for a nursing uniform?

The uniform included a navy blue short-sleeved tunic (arms had to be bare from 3 inches above the elbow), black pants, and shoes. Wristwatches can't be worn, so nurses wear a watch fob-a brooch-style watch worn on the chest that appears to be upside down. I'm still enjoying mine. Although we were told that rings weren't allowed, most nurses wore them anyway.


Tell us about the medical record system.

Nurse charting was kept separate from the rest of the medical record or "notes." Nurses recorded vital signs as "observations," or "obs" for short, and wrote nursing assessments on charts kept at the foot of the bed. This information was accessible to everyone, including patients and families. Patients' names appeared in several places, and I didn't see any effort to protect that information.


Everything at this particular hospital was on paper except for a few things such as labs. I was used to computerized medical records and had difficulty finding the patients' information in these notes.


What was your impression of the other nurses?

Because the nursing shortage in the U.K. is significant, many of my fellow nurses had been actively recruited from all over the world, including Africa, India, the Philippines, Japan, and Australia. Nurses would frequently ask me why I was nursing there, as they longed to be working in the U.S., having heard that we're the best-paid nurses in the world. The fear of taking the NCLEX keeps most of them from pursuing work in the U.S. Nurses I met believed that they'd need to significantly sharpen their skills to work as nurses in the U.S.


It took me a while to begin to understand their system, which involved different levels of nurses. As nurses acquire increased experience and skills, they attain higher levels of recognition and salary.3 Supervisory nurses are called "Sisters."


What was the nursing environment like?

I saw both similarities and differences with the nursing care provided in the U.S. Beds were made very crisply, and vitals signs were obtained and medications administered right on time. Because nurses had to pass tests to perform certain skills, many of the regular direct care nurses didn't perform some duties, such as administering I.V. medications. Agency nurses were commonly employed, some for years, but agency nurses weren't permitted to work with I.V. medications. Newly hired nurses weren't expected to have medication skills.


The nursing care I observed was very thorough. On my unit, many patients needed total care for all of their activities of daily living, which was performed well. Although nursing assistants were available, nurses were always conscientious in ensuring that their patients' needs were met. On the day shift, nurses were assigned an average of five patients.


What was the nursing unit like?

The unit was a large ward of 24 beds subdivided into four groups of six beds with curtains between them. There were three private rooms, and two of them had private bathrooms. Twenty-five people shared two bathrooms; one was intended for men and one for women. Because the census wasn't always equally divided between men and women, bath-rooms were frequently used by both. The bathrooms were cleaned once a day.


The patients were placed in the four groups of beds by acuity and gender, but both genders would be in one "bay" when necessary. The patients whose illness was less acute had one TV to share. Because many patients had extended stays, they'd bring in their own TVs and radios. A pay telephone was rolled around the unit on a cart for patients to use.


My unit had two medication trolleys with one skeleton key each, which would be passed from nurse to nurse. Each medication was kept in its own box or bottle that was used for all patients. Each and every time nurses accessed a box or bottle, they were required to observe the expiration date on the packaging as well as the dose.


Patients who couldn't use the bathrooms used bedside commodes, bedpans, and urinals instead. The soiled utility room had a "sluice" system where the wastes were emptied and the bedpans and urinals were rinsed before being reused.


Tell us about your salary and vacation.

My U.K. salary seemed to be comparable to my U.S. salary, enabling me to maintain my usual standard of living. My income allowed me to take advantage of my location by seeing the local arts and theater and traveling to other countries in the European Union.


We had 12 weeks of vacation per year. The first week I started, I was encouraged to sign up for vacation time because I had a month to use 3 days of vacation before it would be lost.


Was housing available?

Housing was available for hospital staff and students in a large, older building that had been reconfigured into small, dorm-like rooms. While I was there, the elevator broke down, so I got a great workout going up and down the five flights of stairs.


To get good TV reception, I needed to buy a license or face a fine and have my TV confiscated!


Would you do it again?

I'd do it again in a heartbeat! I think this experience made me grow as a nurse and led me to appreciate nursing here in the U.S. I shared my experience with my American peers by chronicling my adventures in an interactive blog.


I just renewed my U.K. nursing license for another year, and I hope that someday I can work as a nurse there again.




1. IELTS (International English Language Testing System). [Context Link]


2. Bournemouth University. Overseas Nursing Program. [Context Link]


3. NHS Careers. Pay for nurses and midwives. [Context Link]