ER Nurse Responsibilities and Duties Around the World

Hi everybody and welcome. Welcome to our monthly show the Lefora Talk Show. This is Season 3 Episode 8 I cannot believe before a talk show has been going for three years. And I am your host, Tanya Freedman, CEO of Connetics USA. We help healthcare organizations all over the United States with a nursing shortage by bringing in internationally educated nurses by direct hire.

Our topic today is clinical differences in the ED How is working as an ER nurse overseas different to working in the United States. We are excited today to be joined by our panel who are going to be sharing their experiences, their insights, their feedback to all of you.

And if you are an ER nurse anywhere in the world looking to come to the United States, this show is for you. And if you're not an ER nurse, this show is also for you, because you're going to learn a lot about how orientation works in the United States, what the day to day responsibilities are of nurses in in the United States, how technology might differ overseas, or how work culture might differ overseas. So we're going to be digging into a lot of topics today. Before we get started, I wanted to just give a shout out and thanks to the Lefora admin team, to Miss Jean , Paul, Luis, and Kaye, James, nurse, one all of the for admin who does such an amazing job of nurses helping nurses. And if you have any questions, please feel free to put those into the chat. I see we have oh, we've got a lot of people joining us ready. Eunice's saying Hi aunt. Eileen is saying hi, everybody morning from Jamaica. Your emergency room nurse in the house. Welcome. Eileen CeBIT is saying hi. Uh, here is, is online. Gigi is tagging a friend. Thank you, Gigi, for tagging a friend.

This is what the forward talk show is all about nurses helping nurses Jancy saying hi. Shearer such is also online. So please put into the chat where you are watching from we'd like to see where everybody is. It's so fun to watch all our viewers from all over the world. So we're going to get started. And a few months ago, we did a poll. And in the poll, we asked nurses in the fora what clinical areas you want to hear about and we did last time we have a graphic of that poll and the last month we did ICU and this month we are doing the ED so today we're going to dig into the ED. Okay, so let's get started. I'd like to start off with introductions. So Sarah, do you want to start off and tell us a little bit about yourself? Yes. So I'm an ER nurse, obviously, that's why I'm here. And I've been ER nurse and for over 14 years, qualified in the UK and then transferred my license to the USA run about eight years ago. So started in the UK then transferred to the US and worked as an ER nurse and then clinical nurse educator after I got my master's degree. Okay, thank you Sarah. So Sara is an ER nurse and will be able to share her experience as an international nurse as well as an as an educator. So we're really excited to hear from Sarah.

Holly Do you want to introduce yourself? So my name is Holly Musselwhite. I am a Registered Nurse of 22 years I have worked with acute care settings and post acute care settings. Never been an ER nurse but worked with a lot of them who come from overseas and help them through that transition. So I work with Connetics now have for almost a year, believe it or not, Tanya, and I enjoy kind of understanding where the nurses are coming from overseas and how their previous practice and what they've been exposed to can help them transition and learn and grow here in the United States. Thank you, Holly. So Holly worked with internet and nurse herself and worked with international nurses for many, many, many years. Helping both nurses and facilities make that transition. Ivan, do you want to go ahead? Hey, good morning, everyone. My name is Adriana burrito. I'm a graduate of Western Mindanao State University from some longer City, Philippines. I'm a travel ER nurse. I'm sorry, might still have my scrubs. They just came back. I mean, I just came home from work. And I'm currently working in I've got Hadley working in the BCS emergency department, the United States. So according to patient volume yet. Anyway, I mean, it's been a privilege to talk to you guys. Thank you, Ivan. And thank you for sharing your insights and your experience. I know there are many people who are going to be interested in hearing about your journey, and what it's like to work as an ED nurse now and I know you're tired. So thank you very much for coming on this morning. And last but not least, Ben, want to go ahead and introduce yourself in.

Hey, good morning. I'm Ben Brian Leonhart. I'm a clinical nurse manager. Currently for one of the largest travel companies here. I have been in health care in the emergency departments working as a nurse and a nurse manager for a little over 12 years. Okay, thank you Ben. So I'll bring it Ben is going to bring another perspective because he is an American ER nurse and has worked in an in many Edie so we'll be bringing a very interesting perspective as well. Okay, so let's start with the basics everybody and I think it will maybe start with Ivan and what was it like working in the ER in your home country and how is that different or similar to what you experiencing now in the United States? Yeah, I mean, I honestly I'm gonna be able to talk for the year nurses work in the Philippines because I just worked for like, a few months as an ER nurse in the Philippines so there are like lots of differences in the in our job in the ED in the Philippines, in job in the ad here work in the government hospital, so I'm not really sure what's the how, how I would how they do in the private hospital, or what's their setting in the private hospital, but basically, where I work at before the, it's divided to specialty, like there's an area for patients who are like under the internal medicine, then there's an area for patients or under surgery, and there's an area for patients who are OB patients and there's also an area for pediatric patients. So the, the rest of the year doesn't have their own private room. So basically, it's just like an open space with like cubicles and curtains that separates the patients.

And here in the United States, as we know, the ED are divided into the depending on which either you work out, like I work in the one of the biggest ad in the United States now. So it is like basically 125 beds, and it's divided into parts. One part is divided by the is equivalent to 12 rooms, and prepared, there's like it's stuffed with the three registered nurses, one charge nurse and techs. So, yeah, so it workwise we, we function here like, like function nursing, so there's like, triage nurses, they're assigning triage, just like five nurses that are assigned to the pad. And there are charged nurses and they're like, service managers and directors then so. Okay, so Ivan, that gives us a very good overview of how things might be different, for example, in the Philippines, as opposed to in the United States. Sarah, what were How is your experience different or the same as Ivan's because you were also an international nurse coming from the UK to the United States? Yeah, one thing I haven't touched on is the ratios that you might have. So he mentioned, you have so many nurses to patients. In the UK, there's no ratios. In California, there are ratios. And that varies also from state to state. I've trained and worked with a lot of travelers from actually. And then they also would tell me about different states that I would wouldn't have ratios in California was great, because they did have ratios. So it would be for patients to one nurse, or if it was a high acuity it would be and the charge nurse would make that designation. Okay, so you seem to have a little bit of Wi Fi delay there. And so, okay, so let's move to Ben. Thank you, Sarah, for sharing.

So Ben. And obviously, you know, there are different size hospitals, different kinds of levels of EDS. Can you maybe share with everybody who's joining right now, how different hospitals might be different in terms of the ED? Yeah, so you'll have your traditional rural settings, which are a little bit more remote, and some of your, your access may be different than if you're working in a metropolis area, which typically are larger volumes. And you'll also have your hospitals that are divided out into trauma centers. So you'll either have non trauma hospitals that see a lot of walk in patients, you'll also have level 123 and four trauma centers level one being the highest. And level four being the lowest of those patient volume, you'll get your walk in patients, but you'll also get EMS transported patients, sicker patients going to those level one trauma centers, as well as those rural community setting hospitals as well. Okay, so not all the facilities are the same. Holly, in your experience, where do you see and I know we're going to dig into the details. So maybe just at a high level? Where do you see into an international ED nurses struggling the most genuinely, when they come from overseas to working in the United States.

The biggest struggles probably have to do with new technology and a lot of electronic medical record keeping versus handwriting things on paper or not using computers much before. And I would say also learning what some of the protocols are both for the facilities as well as some of those more best practice, care pathways and things like that, that may not be standardized, where they're working now. And yet, they provide a process flow for the nurse. So getting familiar with those things, and then sometimes the pace is very different. So they may struggle with how quickly do I need to get up to speed and be working at the same pace as somebody else? Okay, so a lot of good insights there and we're going to digging into some of those things as we move through the next hour. And if you're joining us now, today's topic on the Lefora talk show is clinical differences in the ED how working as an ED nurse overseas is different to working in the United States. And we actually did a poll a little while ago in the fora and it came out that the EDI was I think the first one was the ICU and the second was the EDI and so a lot of people interested in how the EDI is different overseas as well as in the United States. And I see we have Eagle joining us Cecil work joining us Muhammad is saying hi here saying hi to HMI hope I got that right is saying hi. And if you have any questions for the expert panel on the ED, please put them into the chat. And I'd be very happy to to talk about those. And Anais saying hi can Edison was Tanya, Hi Anna, we met in New York. And great to see you here. Megan is make this saying hi.

And so a lot of people joining us and if you have any questions, please make sure to put them in the chat Mike from UAE. And so welcome everybody. And okay, so let's talk he mentioned how orientation or adapting to the US might be different. So let's talk about orientation. And, and that So, Ivan, in terms of your orientation, I know that you didn't work in the Philippines for very long. But how was your orientation in the Philippines different to the orientation you received in the United States I need to work in the Philippines for like six years, but that mostly in the ED? Yeah. Only in the Philippines for a short time, my apologies. No, it's okay. Anyhow, so it depends which hospital you're going through. So mostly in the Philippines, like before, you will be able to work in a specialty area, you need to work like as a volunteer nurse that you like volunteer for like three months to six months. So it means when you say volunteer, you're not paid. So they'll train you on how to become an ED nurse. And for like three to six months, you work like a staff nurse, but you're not paid. So anyhow, so in the United States, like when I first worked in the ED, so I was even like, I think, three months of orientation.

And then to be able to learn things or the procedures, learn about the technology, but as a traveler may move first to become a staff nurse in another hospital. So if you're already a seasoned ED nurse, then the orientation would be like stick shift. So that would be for two weeks, then as a travel ED nurse, the orientation would just be basically, depending on where you're going to be assigned. So one day orientation, and sometimes like just like, half shift orientation. And so because you're already more familiar with the EMR and with everything, so but the training here is definitely better than in the Philippines. And as well as, as we talk about the technology as well. I mean, what I think Holly told us earlier, yeah, it's true. I mean, I think, yeah, tell us earlier about the challenges here, like when it first came here, there's like lots of things that we definitely, definitely have not encountered in the Philippines.

Yeah, and it's not just the clinical aspect, but all of the cultural differences, also difficult as well. And we've done many shows on culture shock. So if anybody's interested in those shows on culture shock, please watch on the Connetics USA international nursing agency website was social media. And we have many shows on culture shock. It's not just the political differences. And Sarah Ivan said that he had three months of orientation, when he came to the United States. How was your What was your experience, like coming from the UK? And how did the orientation that you get in the US differ from the orientation in the UK?

Can you hear me now? Like, my experience was amazing. It was actually tailored to my needs. So we give three months. And every, every week, we would meet with the manager. And yeah, it was really great experience. And one thing I would tell of the nurses coming over to work in the US is that don't be afraid to voice how you're feeling how you feel like you're learning. Because your managers door is always open, it's there to help you. So if you feel like you're, you're needing more shifts on your orientation, that's always an option. Okay, so I was glad, I'm glad to hear that your experience was a positive one. And hopefully for everybody watching, it will be a positive experience. But it doesn't always work like that. And Holly, what can a nurse do if the experience maybe wasn't as positive as either No, Sarah, and they didn't feel that they've got what they needed. From an orientation perspective, what can a nurse do? And it kind of piggybacks on what Sarah was saying, which is speak up, but don't wait to speak up. So some people, you know, day after day, someone may be coming to you saying, how's it going? And you say, I'm fine, or I'm okay. And inside, you're like, I'm not really okay. So you have to actually voice the truth. And certainly, there are things you're going to be celebrating day to day I did this, I learned this, I accomplish this. But those things that you're struggling with, you need to speak up as soon as possible to say, Can I have more practice? Do you have some reading that I could do or a training module or some time with the educator?

And so if you wait until you know, time has passed, and then you start asking for more help or more time on orientation, that becomes a little bit more difficult. The other thing is sometimes we don't have personality matches between a preceptor and the new nurse or the new hire nurse I'll say so at that point, sometimes asking Can I shadow someone else can I can I you know, have a broader experience can also help speaking up is the biggest thing. Yeah, and it's often for international nurses because in many cultures, you know, taught to be timid to be shy, not to speak up not to be assertive. So I think that's one of the biggest transitions that are really, really difficult for many international nurses. And then in your experience working in the ED and managing in the ED, you've been educated in the ED? Can you give us an overview of what and what an international nurse might expect? Just generally speaking, from the ED orientation? Yeah, I think they should be able to expect company competency based orientation. So orientation is really kind of centered or tailored around you your learning aspects.

What, what areas you feel that you need more education and experience in versus areas, you feel as though you're comfortable and maybe have already mastered it. And really just sit around and tailored around you as an individual. So it's really important that you're engaging and speaking up and saying, Hey, these are areas that I feel like I could use more exposure and more education, as well as those areas that are saying, I feel like I'm comfortable in this area, and being receptive to that feedback that's provided to you in those areas. Okay, thank you for that. So Ivan, and I think Sarah also spoke about doing travel nurse, so as part of AMN, and then the largest healthcare staffing company in the country. And talk to us a little bit more about the orientation for travelers. I mean, Ivan was saying he got one day of orientation, there are many international nurses that are very interested in travel nursing. And we've heard some, you know, stories about people who go straight into travel nursing. And it's, you know, very, very stressful. Talk to us a little bit about that, because it's obviously something that can be a great goal for many nurses. But how easy or difficult is it for an international nurse to go straight into that kind of role.

So when the international nurses are brought in, typically brought in for a long term contract. And orientation is very much very similar to as if they brought in a new grad nurse from America to start on the floor. So typically, what they would do is a three to four month orientation, that will be competency based, it would kind of start at the basics, which is very different than, you know, somebody who's traveling, who's used to American healthcare and is traveling from American hospital to American hospital. So it's a little bit different, more tailored and centered around New Grad nursing type of orientation as well. Okay, thank you being so I think important, just to clarify, when Ivan and Sarah are talking about travel nursing, they're talking about traveling around as an experienced nurse in the US. And the orientation that you're going to get for that is different, as opposed to international staffing, where there are some, you know, excellent staffing companies that give very strong orientation and those are more long term assignments. So I think just important to differentiate between those two different areas. And okay, let's talk about the day to day the on the job of what it's like working as an ER nurse in the United States. And Ivan, what was the job? What was the day to day like in the Philippines?

And how is that different to the US? Oh, the day to day, ER nurse life in the Philippines, like if you're in a government hospital, so it's like a full flavor of the day because like, there are days already and there's like lots of patients coming in with acute gastroenteritis, like so basically, like just most of your patients are Aja patient patients, then PTB patients come in like with democracies every day I mean, in one day times, that's the flavor of the day and like our gunshot wounds coming so that's like how it is or the or the flow in the Philippines then so and we said so you're like just focused on one specialty like if you're in the assigning the internal medicine so for the day, then basically your patients will be all internal medicine patients, so I'm not speaking for the private hospitals that I was just able to work in that in the government hospital in the Philippines and yeah, for surgery as well. If you're in a surgery, then basically you're just like focusing more on surgical patients. Okay, so some similarities and some differences, Ed, as everybody knows, one of the most High, high pace stressful nursing roles that you can experience. And Sarah and what is it? Like? What was it like in the UK as opposed to the rays just in their day to day? What was the same and what was different?

Um, it was pretty much the same actually apart from the ratios. So you would go in the start of your shift, and you would see a charge nurse and you'll be given your assignment. But as opposed to what Ivan said, you stick to one specialty. So it would be the ER so you would be given your assignment in terms of a UN fast track, are you in resuscitation area? Are you in triage? Or are you great relief? And you would stick with assignment until you were told otherwise by a charge nurse? Okay, so the day to day though pretty much the same? That sounds like yeah, okay. Yeah. Day to day the same. It's hard to actually give a routine if the ER because it's so fluid you have to go with. But that's what you would do. You would start off your shift see your charge nurse. Give us? Yeah. Okay, delegations. Okay. Thank you, Sara. So, Ben, can you talk a little bit about the day to day of an ED nurse and how that has been during the pandemic? Obviously, we now at the tail end of the pandemic, and, you know, moving hopefully, to a new phase, but what has that been like? And, and, and also, do you see anything in the ED changing now kind of as we move to a more post pandemic phase.

I think we've adapted fairly quickly, in the emergency departments, one of the, you know, the largest changes for us was masking in the emergency department and making sure that all of our patients are masked as well, that was a little bit different than pre pandemic. Also, we changed a little bit of our flows through some of our emergency departments kind of depending on how they were set up. And changing your walk in areas the way we brought patients in. So that changed up a little bit in a lot of the autonomy so the ER is a very autonomous area and you're responsible for a lot and having that ability to recognize some of those D compensations with patients and what protocols you had to act on those that change for the better for the future for emergency departments as well. Okay, so that's interesting to hear about those changes Ivan I know you're working in when the one of the biggest and EDS in the country did you notice what these things that Ben's just mentioned like the flows or the walk ins did that change in your ED definitely would speak like that when I when the pandemic first started, but I was in a different village during that time.

So it was like everybody was afraid to go to the ED so basically, like it was very quiet at first. Like there were no patients coming like only the possible COVID patients were coming so and all the other nurses coming from other units are also in ED because like, during the time, like all the other units, not all I'm saying that the surgical unit was shut down, and many other units were shut down. So basically, they were there to help us out. Eventually, when they became to learn about COVID The people get their vaccine, so they will also like lots of changes, patients started to come back to the end, but visitors were not allowed. So I mean, mask was mandated for everybody. And like we need to thoroughly clean all of our rooms every time we see a COVID patients and there was a time when that we need to like use ultraviolet rays. It's not like for all hospitals, it was in the hospital where it was like before, so And eventually when everybody learned to Robert COVID and a lot of people were more vaccinated. So the rules and policies changed again and I think nowadays it's like probably going to return back to normal. Okay, so a lot of changes and hopefully we back to normal. So in your experience with it, did you experience a lot of changes, as Ben and Ivan was speaking about?

Yeah, definitely having to quickly adapt to what we thought was going to be a huge influx of patients. But like the same as what Ivan said, we didn't see that many patients in the beginning. So again, having to adapt. I also helped a lot of orientation from nurses from other units. Yeah, but now, I haven't been there for a while. But I hear that things are getting back to normal in terms of acuity levels, so people actually going back to their own doctors and finding out that they've neglected their health. So the ER’s are now actually very busy. Yeah, so yeah, lots of changes, lots of adoption, lots of changes. adaptions, getting back to normal, but very busy, normal, because lots of people who maybe missed out on getting treatments and things that they probably would have normally got, if it wasn't in a pandemic world, Holly, the nursing shortage is across the United States. And obviously, the ED is no different in that they are shortages and that the pandemic has created even more shortages. What can an ED nurse do to prepare for coming through working in that day to day environment?

I think that, like Ivan was mentioning that there are differences, where you may get comfortable in one zone of the ER or one specialty, whereas here you may see a mixed bag of issues and concerns throughout your day. So if you brush up on some of the common conditions, and you review, what are some of the best practices from the standpoint of US healthcare practice, which are available online, companies like Connetics, we offer some pre arrival transition training modules to try and help sort of get introduced some of those concepts. And also, if you're, if you're just out there looking online, for what ER nurses are sharing what experts are sharing, getting familiar with the triage process. And, and attending shows like this would be important. I think if you don't have basic computer skills, please work on that. So if you can get access to a laptop, to practice, you know, navigating with a trackpad, or even a handheld mouse. You know, it seems simple and silly. But if it's complicating your ability to transition, you want to try and reduce that challenge as much as you can before you get here. So most people are using phones for a lot of what they do day to day in certain locations throughout the world. But if you can get access to computers and things like that, and start becoming familiar, and that's important, practice standard things like inserting Foley catheters and really focusing on being careful with sterile field seems like such a basic skill, but the focus in the US is on doing things in a way that prevents potential complications. So even though you're in a hurry, the step by step processes that exists are there because research shows that's the best way to reduce risk of complications or injury to a patient who's already ill. Okay, so a lot of very good tips there, Holly. And I want to give a shout out to Sarah who has a channel where on YouTube where she gives a lot of pointers and advice to international nurses, so please check out and Sarah Jeffrey's channel on YouTube. She has some amazing tips and pointers.

As Holly said, there's a lot of information to share. And obviously Sephora is is one of those areas. And that's why we love the Lefora admin team who give this opportunity to share information nurses helping nurses. And just a shout out to tours to Arne to G march from Qatar Gina saying hi Farhad saying hello to you, Ivan. And said you were the clinical instructor during his universities in the Phillip university days in the Philippines one of the best. So shout out to Ivan and oh, somebody's asking about or nurses. So OR was the third one on the pole. So we're going to be doing a show in letter for a talk show on the OR? Yeah. So there we have the pull up. We've done the ICU one. And today is the ED and med surg and  OR coming up next. And okay, so we have a question.

For the panel. Thank you for sharing some questions in so Jairus is asking, is there any advantage if you work in a level one or two Trump trauma facility? And then you want to maybe take that question? Sure. There definitely is a little bit of an advantage, there's going to be more education that's offered to you, there's going to be, you're going to see a wider range of patients as well. So you're going to get to see a little bit more of trauma process and how it affects your normal every day health conditions that the patient may present with, so you're you are going to see a little bit of a broader spectrum of the patient care and get to see quite a bit of the injuries that are associated with that trauma care, which can present to any emergency department regardless of whether or not you're a level one or not. Just the level one trauma centers typically seem to get that on a regular basis as part of EMS brings those in from the community. Okay, so there you go. Jerris Szell is asking can you tell us about the workflow in the ED Ivan you're working in one of the biggest EDS in the country talk about let's hear about a little bit more about the workflow Yeah, I mean, I'm getting add with the advantages from level one traumas are level three traumas okay? Just in my opinion so the but there's also a downfall working level of trauma or Level Two trauma because they tend to like they have like these hospitals are usually they have like lots of policies so you won't be able to be able to master your skills like unlike if you work in a level three trauma then it could like master your skills like you can insert EJ switches that for level one trauma six that like allowed and solo IVs you can definitely use it in level three trauma hospitals. So I'm just saying basically, skills wise, it's also nice to be able to work in a level two trauma hospital or hospitals that are that doesn't have a trauma hospitals because you'll be able to, like you'll be able to experience lots of things you'll be able to

I'm sorry, against that working. Attending that the nurses or I'm working at that, definitely you're learning more skills when you work in level three or level four hospital trauma hospitals. So anyhow, so for the questions like What was the question again, I'm sorry. But as the talk to us about the workflow in the eat the work the workflow in the ED may be a walk in patient or an ambulance patient, of course starts with triage. So as what Holly was talking about earlier, definitely in need to learn more about triage Oh, here in the United States, so the use the emergency Severity Index to be able to triage patients at graduation from activity levels 12345. When you learn how to triage and you will be able to like prioritize, where to put the patient if the patient can go directly to the room, or the patient will be able to stay in the waiting room like in our hospital right now. So it's the PCs, according to patient volume. So we usually have like 80 to 100 patients in the waiting room. So it's actually a tough scenario for triage nurses, because you need to decide whether the patient needs to be a walk back, walk back or not. So where am I? Right now if as soon as the tragic patient if the patient is like a sick patients, then we're going to mark the patient for as soon as the patient is my preferred. Another nurse is responsible for assigning the room for a patient which is the EMS nurse so the EMS nurse is responsible for assigning roles for patients so she was assigned the room for patient then we'll put the patient in the room patient will be assigned to a nurse afterwards the primary nurse will be taking care of the patient and the Prime Minister's will do his or her primary and secondary assessment.

So in different hospitals, you can throw in your set of orders like if the doctors are busy then you'll be able to throw in a chest pain set of orders or abdominal pain set of orders and you'll be able to start your IV draw blood sent to the laboratory but in level one trauma hospitals usually need to wait for since it's a teaching hospital, you need to wait for doctors to assess the patient and unfortunately to be paying for doctors to be able to like study how to do their assessments and put in their orders. So it usually takes time so the pacing is usually slow in level one trauma hospitals then so anyhow after that, you'll, you'll start to find your EKG, it'll blood set, set it, and then you wait for results. And after everything's set, then the next step would be for the doctor to evaluate results, then after that, then the last step would be for them to decide on their disposition, whether they're going to keep the patient or admit the patient, whether they're going to discharge the patient or whether they're going to they're going to transfer the patient to another hospital.

Okay, so that gives a great explanation of the workflow. And as you're speaking, I'm just thinking how I love the look for a talk show. Because for many international nurses, if you're sitting outside the US now, and you hear what Ivan has just explained, it just gives you such a great idea of what to expect. And that's where knowledge is power, the more you can learn about what's coming, and how to empower yourself, the better equipped you're going to be when you arrive in the United States. So we have some questions coming in now. And Zell is saying, thank you well explained. So there we go. And so and G Marge is asking, So in regards with the triage, are you using the CTAs? I, as I mentioned, it's ESI emergency Severity Index. I'm not sure if a CTS is Canadian triage system, but they're similar because I think the Canadian triage system is also like, I think it's four levels or five levels. But the unit basically triage like level one is the urgent emergent patients like the patient needs to be like, attended right away like patients, where were they going to cardiac arrest, or the patient is under respiratory arrest? And definitely you tell the patient this one patient needs to be brought to a critical room right away. So I'm not sure exactly if CTS dyskinesia and triage is there, but we're not using it Sarah and Holly been nodding their heads and Jr. Saying yes, that's Canadian. And Jay, is saying yes, I think the majority and the US are using the ESI. And in Arlene is saying in Jamaica, they use that a two as well, then is that correct? Most hospitals here I use the ESI?

Yes, most hospitals here are using the ESI triage system. Okay, thank you. So that that's kind of a good segue to moving to our next topic, which and Holly actually spoke touched on, which is the technology piece. So and we want to dig a little bit deeper into this. And Sarah, what were the technology differences in the UK as opposed to the US? experience as a neediness? If any. When I when I first started nursing, there was no technology. It was all paper chart and such was when I called in base era. But I'm now Yeah, then then I was part of the train and the enrollment to the ER, the training process when we move to computer charting, which was great. Okay, yeah. So not a not a huge amount of difference for you in terms of Oh, no, it was its clinical chart. And it is what it is, you write what you see. And if you don't write it down, it didn't happen. Okay, those are the words. So if you're coming from a country like the UK, like Sarah did, really not a huge transition. I mean, you might have to learn a new system, but you've still also had that experience of working with electronic medical records. Ivan, what was that like for you coming from the Philippines in terms of technology? Not that yeah, it's sad as mentioned. So definitely the charting. We're still using the paper system here we're using the EMR so for paper system usually the basic from nursing care plan so we'll do this so P charting in the EMR, definitely, it's more specific and like, you'll be able to chart everything from head to toe assessment. So aside from that, technology wise, of course in the Philippines when you start your IVs just basic IV insertion so here we have like, lots of options like if the patient is hard sticks will be able to get the vein finder or if you can find steel with a beam finder and you'll be able to use an ultrasound-guided IV insertion and all of the rooms here so their cardiac monitors in the Philippines, we don't we don't have them.

They're their residents. So they're basically lots of differences then you as what Savannah said earlier, so you definitely have an autonomy here, as an ER nurse in the dock in the Philippines the order for the for everything here subset we, we can throw in a set of orders, and we will be able to start the care of the patient. Thank you, Ivan. So, obviously, technology is one of the biggest transitions if you're coming from a country that does come from the paper that are still using paper methods right now. And not only that, in the US, we are also seeing a lot of new technologies that are becoming available. And then in the ED, what are some of the newer technologies or things that nurses might encounter? I definitely think one of the big advances that we've had in the last several years, as it comes to electronic charting systems is our scales and screens. So now most of your skills and screens are built in. They help you identify things that are happening in the background. So a lot of systems have sepsis identifiers that are identifying some of your lab work versus some of your findings that you're documenting and charting with your vital signs. And they're helping you to identify some of those more critical situations, which may be happening with your patient that you're not readily maybe not on the thought process of, for instance, sepsis, or stroke.

Patient, the possibility of patient violence and agitation. So we've come a long way with scales and screens, based off what we're charting in our electronic systems, and all that information kind of pulling together to give you an alert. And that's  something that's it's been progressively happening for the last several years, which has been a huge benefit to the to the bedside nurse. Yeah. So there's lots of changes and evolutions coming, which is great for the for nursing in general in the US, but makes it sometimes even a little bit more challenging for those nurses who coming from countries where they are, there's they still, you know, with paper charting highly, you spoke a little bit about how nurses can prepare from a technology perspective, especially if they're coming from a country that has still has paper charting. And can you speak a little bit more about what you seeing are the biggest challenges that nurses experience in terms of the technology and you know, any other additional tips that they might have, that you might have. So I don't see as much narrative charting. But when it is done, it needs to be very succinct. But as Ben was pointing out, there's a lot of scales and things that are built in and if you are using the EMR correctly, and you're kind of making that something that is part of your thought process to let me make sure I get this sorted timely, then you're more likely to capture things that may help you intervene sooner, because the system is there helping you kind of put it all together, it's programmed that way.

I'm using a mouse, which I don't even have one at my desk right now I'm on a laptop. But using a handheld mouse in some ER’s, they still have desktop computers, but a lot of times they have laptops with trackpads, and things like that. So again, practicing just kind of clicking boxes and getting familiar with operating from that standpoint is helpful. On the internet, you'll also find exposure to some of the most common systems that are out there, there's little videos and things like that it won't look identical because every system can usually customize their EMR specifically for what they're looking for. But you can see kind of how it might appear some of the fields and the colorations. So the most common systems are epic. And Cerner, I think they're probably they kind of cornered the EMR market. And those there, there are things out there that you can look for related to that. The other thing to be aware of is that we know time in the ER is really something that you can't afford to waste. So a lot of the systems are also built around timely interventions, timely testing, timely recognition. And so you know, those alerts and those prompts, if you're not really using the device the way it needs to be used, because kind of like I don't really like that. Unfortunately, it's an it's a necessary thing. And it really needs to be something you view as a helpful piece of equipment, not an annoyance or something that's going to cause you more frustration because it's really meant to help the bedside nurse and the patient. Okay, so they will attitude is really important when you are encountering that challenge, and that can often be the biggest challenge for many international nurses.

So far. HUD has a question for the panel in the case of a bait crisis in a general ward are they admitted patients stay in the ER and for how long? Then? Can you maybe take that question? Can you repeat the last part of that question for me, we so far hard is asking, in the case of a bed crisis in a general ward, are the admitted patient staying in the ED and for how long? I think during the pandemic, I'm not sure. Yeah. So every now and then your hospital may run into a bed crisis. And we have typically what kind of in our verbiage we refer to as a border in the emergency department. different hospitals handle this situation differently. Some hospitals have inpatient nurses who come down and care for those, those boarded patients in the emergency department. Some hospitals rely on us as the emergency department nurses to take care of those patients in the emergency department. It just kind of depends on what the policy and procedure for your hospital is, as well as the availability of resources. Okay. But it does happen. We're seeing that it's happening a little bit less than, than it did happen several years ago. But it is something that comes around every few years. So it can come up. And different hospitals, you know, might handle that differently for heart. And one thing that is not that different, and that that everybody would encounter in any hospital is that the word culture in the United States might be different. So our last segment that we're going to be talking about is the word culture in the ED. And Sarah was the word culture in the ED in the UK different to the US, and if so how or if not how?

Yeah, it was, that's one of the things that I found the hardest actually the work culture that the hospital that I trained in was more, there was a team nursing, because they didn't have ratios. So nurses would stick together, and they would tackle patients in a team. And funnily, I hear this a lot on nightshift, they do more of a team nurse and approach a night shift. As opposed to day shift in the US, you have your four patients, and those are your four patients. So that's one of the things that I struggled with, with rather than it's the ER, everybody takes care of that patient. It was, it wasn't, it wasn't a pleasant experience in the beginning. But once you get to know the workflow, you get to know the staff. And when you are in a situation that your patients are kind of taken care of, and you offer your help to another nurse, that was definitely that helped me when it was the other way around. And I was struggling, and they were they were taking care of they would offer their help. So just communication really, really helped. So that was a big adjustment. And so that's where, you know, it's not sometimes just the clinical piece. It's also the work culture and dealing with a different model of nursing that can be so different and can you talk a little bit of time to adapt to Ivan for many nurses coming from the Philippines, one of the biggest cultural differences is the relationship between the nurses and the physicians. Can you speak a little bit about that and how it's different and how you had to adapt when you came to the United States? What advice would you give international Ed nurses coming from the Philippines? Yeah, definitely. They will be a surprise. But yeah, in the United States, you're  open for, for any suggestions, you can talk to the physician and aquity, the considerate physicians and nurses like ours as equals.

If he'll make a suggestion, they will listen to your suggestions and he will be solely like, order it as according to your what you think. So in the Philippines, actually, when the physicians might get mad, but the some of them are they think that they are godlike over there. So they think that the nurses are inferior. So they think that nurses should follow everything that they say and they the nurses should follow all the orders that they have ordered. And so he I think that the this would entice the Filipino nurses to come here like, that's what what's beautiful here in United States, like all members of the healthcare are our equal so mean, all of your opinions are suggested or taken accordingly. Okay, so a very big difference in the dynamic between physicians and nurses, not just in the Philippines, in many countries all over the world. And that, you know, can also be a big area of adjustment. Yeah, hate zero. Yeah. Can I just touch on that because that's one of the positive things that are found in that, actually for nurses in the US. That is expected is when you work with doctors, they expect your, your clinical decision making to come into play. So if, because they're very busy seeing multiple patients, so if something's wrong with your patient, they're, they expect you and they trust you as a nurse to come to them and say, look, I think we need to order this lactate, or I think we should do a repeat EKG. So that's one of the things that are really enjoyed, about transitioning to the US. So nurses have a lot more autonomy and independence in the care model. And for many international nurses, that can be a challenge, because, you know, as we said, nurses are sometimes taught in different cultures to be shy to be timid, not assertive. Holley, what can a nurse do if you come from a culture where you are not assertive and taught not to be assertive?

I think the first thing is to acknowledge the difference to Yes, it exists and also to practice in less high pressure setting. So for instance, if you go to a store, and you can't find something, it can be really hard to ask for help. If you're in a place you've never been before, in a culture, you're just learning. But speaking up, even in something basic can be a way to kind of free yourself from that norm. Practice it even before you get here, when you're if you're able to in the in the country that you're currently practicing in. You know, sometimes it's a mannerism that's learned over the course of your entire life. It's not just in healthcare, it's your culture. And so you can find ways to say politely, you know, this is really concerning for me, do you mind if I share my concerns? The other thing is that assertiveness is not aggressiveness. So assertiveness is bringing something to the forefront and having a conversation about it versus really being pushy. And those are two very different behaviors. So practice is really what it's all about. But I'd say if it's totally foreign to you start in your community, start in the new community, reach out, make friends, that's actually something you want to do to prevent burnout is to start to build connections. And the way you do that is actually be more assertive. Okay, so lots of great tips and pointers there. And it's really just the mindset that I think is so important. And just looking at the time we are almost at the hour, I cannot believe that the hour has flown by this has been such a fun and interesting discussion. I think final words, and let's maybe start with then what would you say is your one biggest piece of advice? You know, you worked in many EDS, you're very experienced in the US system. And you've seen as part of AMA and many international nurses come through what is your best advice to international nurses coming to work in the ED?

Definitely research, you know, the Emergency Nurses Association has a website out there that has a plethora of knowledge and educational resources that are available to you doing that research and kind of plugging out and kind of figuring out what is what and knowing where to be able to turn to find those answers as well as communicating with other ER nurses from across the nation and across the world. I think that's an invaluable resource to any emergency department nurse. Yeah, absolutely agree. 100%. And we'll post into the chat, the website that Ben just mentioned, before anybody who's interested in the resources that can be provided. And as Ben said, research is key and reaching out to the community, which is what the fora that before a forum is all about. It's about community. And Holly what would you say is your biggest, what would you say is the biggest mistake that you see nurses make and where you would like to maybe give your advice. The biggest mistake would probably be making assumptions. So assuming one way or the other, that you're not doing well, or it's not good enough, or that you are doing well, assuming without clarifying, and without communicating is probably the worst thing you can do. So it does go back, as we said earlier to communication, asking for things asking for feedback, being upfront about the things that you know, see yourself doing well in as well. So things where you want to do better and reaching out. Remember that there are resources if you're connected with an agency, like Connetics, you have resources there, you also have resources in the hospitals and you want to make use of those. If you don't, you'll find yourself drowning very quickly. Yeah, I think that's great advice. And Connetics have many resources AMN have many resources AMN and family have many resources as well.

As many other reputable companies that do international staffing have many resources, so do your research and your homework in that regard. And Sarah, in in your experience of coming to the United States, what is something that you wish you'd known before you left the UK about working in the ED? you unmute it, something I wish I'd known. Yeah, I'm probably just to trust my own instincts a little bit more, at the end of the day. It's a patient that's in front of you. So no matter where you are in the world, you still have those clinical pointers that, you know, haven't gone through nursing school haven't gone through training. So just to trust yourself a little bit more. Yeah, I love that. Because I think for many international nurses, you're just thinking all the time, I don't I know how difficult they're going to be what a struggle it's going to be. But you're a nurse, you're a qualified nurse with experience. So you also have to be able to trust yourself. And I've been final words of advice for any ED nurse that is going to is thinking of coming to the United States is on Route in the immigration process to come to the United States has just arrived in the United States. What are your final words of advice?

Well, I think what they've mentioned earlier, he said, what we need to learn in ED is learn how to talk and ask questions. So definitely we don't know, all of the procedures. So we're not the knowledgeable of all the cases that we're going to handle. If we don't know, then make sure to ask the questions that we will be able to avoid mistakes, because definitely miss we know like, there's like lots of low suits here then. So that would protect your license. And I guess, read more, as Ben said, so OBD II and a website. Read more to be more familiar with what emergency nursing, it's about here in United States. Thank you, Ivan. So and that's what the Lefora talk show is researching, learning more, and really preparing yourself for the transition, which is going to be one of the most difficult and stressful but also the most exciting, and one of the best and the best experience that you can do as an immigrant myself. I came here 22 years ago, I you know, speak from experience as well.

So I wanted to thank and Ivan, Sierra Holly and Ben for joining us. This has been a fun discussion. Thank you to everybody who's been watching from all over the world. The love for a talk show. We'll be back next month. And that with a new topic, if you have a topic that you want us to cover, please make sure to put that in the chat and we are one team we want to make this as fun and interesting and informative as possible for you. And before you leave us just don't forget the upcoming shows. And so we have some upcoming shows and on the onwards and upwards the Connetics channel on the 23rd of September we have the topic of how to rent an apartment in the United States. On the seventh of October is next generation NCLEX exam on the 14th we have our regular immigration Q&A And on the 18th and love for a talk show we are talking with the Philippine Nurse Association in the United States and what they can offer international Filipino nurses coming to the US on the 21st in stateside we'll be fine highlighting North Carolina. So what it's like to live and work in North Carolina, and on the 28th we'll be speaking about your spouse. And last but not least the Connetics college every Monday please check the time in your location.  And we have classes on Niners are talking about IELTS vs. OET VS NPTE on the 26th and PTE class by switch on the 10th of October Aspire class on the NCLEX on the third of October. And on the 24th of October we have nine as again and oh sorry, I missed it on the 2017 first NCLEX and from IPASS and Niners on the 24th. And so thank you everybody for joining us joining us for the fourth talk show and we will see you next month. Thank you bye bye