My former manager said that a nurse is a nurse regardless of where he or she practices. Of course, this partly refers to our ability to flex and float to another unit. However, if you look at it from an immigrant nurse’s perspective, it could also mean that you are able to practice as a nurse no matter what country you are in. However, the opposite is true. Yes, culture shock does exist in nursing jobs, too. Below are the common reasons.

Nursing Education Patterned After the American Standard

Philippine nurses are enjoying education patterned after the American standard. This originated during the post-Spanish American war era in the early 1900s. American missionaries established and operated Iloilo Mission Hospital in 1901. They trained nurses based on the American or on the Western curriculum. Ever since then, the nursing curriculum in the Philippines has been patterned after the American standard. Maybe because of this, most nurses are preconditioned to plan on migrating to foreign countries for better lives.

With the uber abundance of nursing graduates year after year, it is understandable that landing a stable nursing job or nursing practice is not guaranteed. Low wages, training expenses, and extreme competition among peers force nurses to opt to find other means of income. The proliferation of business process outsourcing (BPOs) or call centers in the Philippines attracted nurses to make more money compared to working in healthcare facilities.

http://pexels-rodnae-productions-6129689

Differences in Clinicals

If you are a Philippine-educated nurse, you will remember the hours upon hours spent on your related learning experience (RLE). Those were the “duty” hours wherein nursing students practiced their skills and knowledge in patient areas be they in the hospitals, clinics, or in the community.

I distinctly remember that the tasks assigned to us evolved from simple to more complex as we progressed in school. First experiences included bed making, checking vital signs, and assessing the patient’s lung sounds for example. Before coming to the hospital wards, we had ample chances of practicing those skills among peers and family members.

That abundance and variety of clinical exposure are what sets up apart from other nurses educated in other countries if you ask me. The ability to handle patient caseloads on our own as students already cultivated that self-confidence necessary in the job. We even managed the whole unit ourselves during our senior year. Once out of nursing school, we feel sure that we have perfected our assessment skills because we have done it at least a hundred times with different patients from different age groups.

On the other hand, local students rely heavily on simulation practices for their clinicals. They are very knowledgeable about the proper management of patients, but the hands-on part is lacking. The pandemic even made it worse. As I shared in one of my previous posts, I met a group of students who had exposure to the special care nursery as their only onsite clinicals prior to graduating.

Innovation versus Readily Available Supplies

Due to the Americanized curriculum, I remembered feeling confused about reconciling what I read in the nursing textbooks and what I was expected to do in real-life scenarios. For example, I took care of a patient with a colostomy. The book stated very distinct steps on how to change a colostomy bag, I didn’t have the slightest idea of where to start because I don’t have any of the materials mentioned in the book. This actually inspired me to be creative (e.g. use a smaller plastic bag and a rubber band). However, I now question myself if I caused the area to be necrotic due to what I did.

As a former clinical instructor, I would always start our clinicals with this line:

Our books have standards we have to follow. However, we have to be realistic and consider our resources. We then adapt our actions based on that.

In a nutshell, we encouraged the student nurses to follow the textbook as situations permitted.

Coming to America, I finally saw those supplies firsthand. Back to my colostomy example, I asked my colleague to demonstrate what I needed to do. At that moment, I didn’t even know how to peel the adhesive, much more resize the hole to fit the patient’s colostomy.

The Obvious Gap in Technology

It was not only the lack of supplies that we struggled with. Ever stood by the intravenous (IV) bag and manually count the drops to calculate the rate? I sure did that, and while administering a chemotherapy infusion, too!

Another thing that I recalled about working in the Philippines was when on a busy shift, we completed our charting at the end of the day. My colleague and I would usually share a cab home at 1 in the morning. That was because even if our shift ended at 11pm, we had to document and carry out doctors’ orders in 30 or so charts.

Working in clinical informatics now, that experience continuously inspires me to make the electronic health record system more efficient for clinicians. I shudder at the thought of deciphering a doctor’s shorthand strokes in a life and death situation. And still get yelled at after the fact, if we didn’t carry it out correctly!

In first-world healthcare systems, only a handful of organizations are still using pen and paper. For new immigrant nurses coming into nursing practice abroad, this may be challenging for them. I have personally helped a few navigate through the complexities of computer charting.

Multidisciplinary Collaboration

I mentioned earlier that I had my fair share of incidences wherein the doctor yelled at me. Some of those may have been warranted, while most, not so much. We all make mistakes, that is a fact. However, it is not really what is being said that matters, but more so how was it delivered?

If you are like me, you will be familiar with the hierarchical healthcare structure. As a newbie nurse, I understood back then that I was a subordinate to the doctors I worked with. Although I had my own independent nursing practice functions, most of my work relied on the doctors’ orders. They decide what medications the patients need. They figure out what labs are necessary.

It will be surprising to new immigrant nurses to find out that as part of a multidisciplinary team, doctors and nurses here mutually respect each other. We each have our distinct but interdependent roles to play. Since we closely work with our providers, it will benefit us and the patients, more importantly, if we learn to collaborate well.

I still make mistakes. Sure, providers or leaders will call me out for them. However, healthcare organizations discourage yelling or bullying. They are detrimental to the person, the team, and the organization as a whole.

http://pexels-sora-shimazaki-5669619

Navigating the Legalities of Nursing Practice

Back home, it is very rare to hear about legal actions taken against nurses or other members of the healthcare team for that matter. We have policies and laws that protect both the patients and the clinicians. Sometimes there may be some bending of those rules, but taking legal action is not a common go-to option in the Philippines.

Here, when mistakes happen, they are thoroughly investigated. Just culture is then initiated. The leadership and the Risk management department will look into what policies, mandates, or laws were not followed. The consequence (e.g. suspension) is then implemented. If the nurse is not amenable to that consequence, he or she has the recourse to reach out to the grievance committee.

Healthcare organizations follow mandates defined by the federal, state, and local governments. Furthermore, accrediting bodies such as The Joint Commission also oversee compliances.

Simple actions such as posting a patient’s protected health information on social media will result in sanctions as defined by each organization. it is therefore important for nurses to be mindful and purposeful with every action they undertake. If unsure, they have to be honest and talk to their leaders so that they can be guided accordingly.

http://pexels-mohamed-hamdi-4035826

Final Words

Some may misconstrue this post as dissuading foreign nurses from leaving their comfort zones. In reality, this is an eye-opener about the realities of nursing practice that awaits them in first-world countries. The reason why I wrote this in the first place is, that I wish someone told me about these before. Maybe, I would have been better equipped with my expectations and mental preparation.

Life is difficult, there is no sugar-coating to this! Nevertheless, if you are determined to reach your goals, you will work hard for them. My only hope is that this post will somehow give you that extra information that nobody may be forthcoming about.

Do you now feel ready to cross that ocean to chase after your dream nursing practice?