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The American Healthcare System vs Other Countries Nurse Experience

Hi, everybody. Hi there. And welcome. Welcome to our monthly talk show. This is the Lefora Talk Show. And it is episode three. So season three, episode five. Oh, my goodness. I cannot believe we've been doing this for three years already. We are so excited today. My name is Tanya Freedman, and I am your host. I'm the CEO of Connetics USA, and I have with me an esteemed panel. We have Gillian. Hi, Gillian. Welcome. Hi, Tanya. Thank you for having me. Great to see you, Gillian. We also have Cornelia, who is no stranger to the show she's been on before. Hi, Cornelia. Welcome. Hi, Ms. Daniel. Hi, everybody. Hi. Nice to see you. And last but not least, we have welcome. Holly, honey, can you hear us? Good morning. Good. There we go. I think we had a little delay there, honey, but welcome, everybody. Good morning. Today we have a very interesting show. Our topic is clinical differences in the US as opposed to overseas. And we're going to be talking about a lot of very interesting items that are really important for nurses to know about before they come and live and work in the United States.

So we're going to be talking about what some of those clinical differences are. We're also going to be talking about orientation, what a nurse could or should expect from an orientation in the United States. We're going to be talking about On The Job training. We're going to be talking about technology. We're going to be talking about cultural differences. We're going to be talking about culture shock. So a lot of very important topics for any nurse anywhere in the world who is planning or wanting to come to live and work in the United States and to learn what it is that you can expect. This is what I love about the Lefora Talk Show. The talk show is Nurses Helping Nurses.

So before we get started, I just wanted to thank the Lefora Admin team who do such an amazing job. So thank you to Louise, to James, to Nurse Juan, to Ms. Jean, to Paul, all the four admin who do an amazing job. And thank you for giving us this opportunity.

So let's get started. I'd like to start off by having our panel introduce themselves and give us a little bit of background. And I think let's start off with Cornelia. Go ahead, Cornelia. Tell us a little bit about yourself. Yeah. I came here March of 2021 through Connetics. I've been working for more than a year now here in California as an RN. I came from the Philippines. I worked in one of the biggest hospitals there. Okay. So, Cornelia, I know we're going to dig in a few minutes. We're going to dig deep into the clinical differences. But just overall, what was this experience like for you? It was a very beautiful experience for me. Life -changing experience, so many challenges that I was able to overcome so far. It's been good. Okay, good. Well, we love to hear that.

And we're going to move now to Gillian. Gillian, do you want to tell us a little bit about yourself? Yes, of course. So I actually came from Trinidad and Tobago in the Southern Caribbean, and you're hearing my accent. You know, I'm not from the US, but my story is almost identical to many of our nurses out there who are listening in where I wanted to come just for a chance at a better career here in the US, better life for my family. So I made the move. It's about 17 years now since I've been here. And just like those of you out there, I came wanted to come. I started my assignment, and I've been through so many changes because it's so very different from other parts of the world here. So it's been great. And I've never regretted it. Well, we love that you've had many years of experience in the US, Gillian, and also bringing a different perspective to Cornelia because we talk about international nurses. But it depends where you come from and your background, how you're going to adapt and adjust to life in America.

Gillian, tell us a little bit about your role right now on what you do. So right now, I'm the senior director for clinical services, one of the senior directors for clinical services at AMN Health Care. And as you know, we also have international nurses come into the US. So at AMN Health Care, I have a team of clinical managers, and we provide clinical support to our nurses before they come to the US. And while they're here, we provide support to them as well. So the goal is to help them to be successful in their transition to US practice.

Thank you, Gillian. And I think that's going to really give a great additional kind of edge to this conversation because Gillian has been on both sides of the fence. She's coming as an international nurse. So had that experience the same as Cornelia, but is now on the education side for AMN. And so we're really excited to pick your brains, Gillian, and for you to help international nurses that are watching all over the world today, both in Lefora as well as on the Connetics USA page, onwards and upwards, learning about your experience and what to expect and how to prepare. Last but not least, we want to welcome. Honey, honey, tell us a little bit about yourself. Well, I am also a nurse by background. However, I've not practiced overseas. I've been a patient in the Philippines, if that helps. So that was an interesting experience. But I grew up in the central Florida area and spent most of my nursing career there. I've been a nurse for 20 years. I've been a preceptor for many nurses from overseas, from all different countries and backgrounds. And I've always found it fascinating to learn not just how what we do is different, but some of the great things that are done overseas that maybe we can take and learn from here. So I like an exchange of information. That's why I'm really excited about this particular session. And currently, I work with Connetics as their clinical educator. So some of the nurses who are on our programs will hear from me in relation to transitional modules NCLEX programs when they're on assignment. Sometimes I serve as a resource. I work with our facilities that we partner with when we're having some of our nurses go to start work there and help figure out what are some of the best practices that can help a nurse be set up for success when they have no US experience.

Of course, there's so much more than just the clinical that's going to impact your transition into the US. But we know that if you're aware and you're more prepared that you stand a better chance of surviving that transition with a little bit less trauma. So we love the opportunity to talk about these things ahead of time and give people that opportunity to start to think about those concepts and put them into practice. And I'm really excited to hear what everybody's going to share this morning. Well, I think you also bring a great perspective, Holly. Having been a nurse here for many years, precepted many international nurses. And I love what you said about an exchange of ideas because it's not just about what's bigger and better in America. It's also what we can learn from international nurses and how to have that conversation. So let's begin the conversation for everybody who's watching all over the world. Please put into the chat what your name is and where you're watching from. We love to have interaction from our viewers. And if you have questions for the panel, please put them into the chat because we really want to hear from you. This is a conversation. This is sharing of ideas, sharing of resources. And I think that a lot of nurses are going to learn a lot in the next hour.

So let's get started. So I would like to start with Cornelia. Cornelia, let's talk about orientation. Can you tell us a little bit about your orientation and how it compared to the orientation you received in the Philippines? And was it what you expected my orientation in here, we spent about a week like a discussion with different clinical instructors. They explained to us how to use the computers, on how to use the computer charting. And then after a week, we spent about   month in the hospital shadowing a senior nurse. Good thing I had a Filipino Preceptor. She let me handle all my patients. She was just on my side watching me what I need to do and telling me what's not to do. So it was more the hands on experience for me. So when I transitioned from my preceptorship to being on my own. It wasn't that hard of a change for me in comparison to my orientation in the Philippines. We spent more time on discussion and less time on shadowing a senior nurse. So it was harder for a nurse to start a job in the hospital because on the first day that you start on your own, it seems like everything is still new. So it was a better orientation here for me. Okay, that's interesting. So I'm glad that you had a good orientation, which is great. And it sounds like in the Philippines for your experience was more kind of theory based. Yeah. In here. Also, they will ask you before you go on your own, are you ready to work on your own or do you want to extend your orientation? So you will also have a chance to request you can request for another month long orientation if you feel like you're not prepared or you're not ready enough. So you also have that choice here.

Okay, so I see we have a Facebook user who says if you're not comfortable working on your own, can you request for an extension in your training? Yeah. So you can extend for another month or another week. It depends on you. So they will not make you work on your own unless you're prepared enough. Okay. All right. So that's good to know. And I think can probably give some nurses a lot of comfort. And also just to bear in mind, everybody different hospitals might be different in how they actually structure the orientation.

So I see we've got Luci, who's saying, love this panel. The fora Connetics and AMN. Yes, Connetics nursing recruiting agency has been acquired by AMN recently. So we really decided to have Amen join us. Arlene is from good morning from Jamaica. And we've got Raul. He's watching from the Philippines, Michelle from the Philippines, Meryl from Riyadh, Alma from the Philippines. Butter Dom is from Saudi Arabia, excited to go to Sanford, North Dakota. How many weeks of orientation is it paid? So we will speak about different hospitals orientation. So that's a good question. And yes, it is paid. Reneesha is from the Bahamas. Milana is from the Philippines. Sapphire is from Dubai, minimaI from Dubai, O. R. From Singapore. Yay around the world. We'd love to see it. So fun. Please, everybody, put your questions into the chat for the panel and we are here for you. We want to answer your questions about what the clinical differences might be when you come and live and work in the United States and how to prepare for that.

So, Harry, can you talk to us a little bit about different hospitals orientation programs, how they might differ, and what are some of the best practices that an international nurse might expect? Okay, sorry to interrupt, honey, but not everybody. Canada had a great experience, but not everybody has that. No. And I think it's fair to mention that sometimes if you're expecting something even within the same hospital that Cornelia was at. Sometimes different units have different approaches. So what you want to do is prepare yourself as best you can. I'll talk a little bit about that later. But in terms of orientation, there are some common things that we see amongst facilities. Most facilities have at least one, maybe two weeks of orientation where it's more theory based. It's not all clinical either.

So some of it is an introduction to what are the company policies, what are the compliance things, what are the security issues in terms of being safe on the facility site, being safe with the data that's being used. So some of it will be more heavily clinical and some of it will be non clinical and some of it will be more about the technology. So we find that different facilities have different volumes of the content that's going to come. They also deliver it differently. So many facilities after the Pandemic shifted from a more face to face classroom type of model for a lot of those required trainings into using more online training services. So they may actually bring you in situ in a classroom with a computer and say, I need for you to complete these modules before we move to the next phase of your training. And sometimes that may seem a little bit hands off. But we also know that in terms of social distancing and some of the rules for being saved during times when the pandemic was at its peak, we learned that we could do things differently and still get messaging across that was effective.

So what we want to do is ask questions if we're not sure what the content being covered might be telling us, or if we're coming away with a message that's unclear. What the hospital assumes is when you're doing those training modules that you are understanding the content, and then if you don't and you go to practice on the unit and you're asked to do something and a concept was being introduced in a module earlier. If those dots weren't connected, then it's time to speak up and advocate for making sure that you do understand the content. The reason for that is ultimately we are responsible for patients. One of the things that you will hear a lot and it's a prideful thing for us is that in the United States, they survey and have surveyed the public for years about what profession is one of the most trusted. And there's always a list that comes out. And not surprisingly to me, nurses are often and I think for many, many years have been at the top of that list. It's a very trusted profession, and it's because we do take the time to advocate for the patients that we're taking care of, and that includes trying to address things that we don't understand so that we can go out and practice nursing safely and take care of those patients safely.

So once we've had that clinical and company orientation, one, maybe two weeks, and you go out into the field with a senior nurse or a preceptor. The preceptor is often going to be chosen from someone who maybe has longer experience in the facility or someone who is willing to teach a nurse or a new nurse or a new hire nurse how to practice within that facility. And so they may be prepared or have worked with nurses from overseas before, and they may not have they may be, as Cornelia shared, a nurse from the Philippines, which is really awesome. And it may be somebody who's not from the Philippines, not from overseas, has never had the opportunity. And what you want to do is keep an open mind yourself. Don't go into it feeling that because this person hasn't done what I've done, that they might be more judgmental towards me. Because if you do, sometimes that colors your approach. So when you're working with that preceptor, they do expect you to be hands on. And Cornelia talked about that, doing things, doing things, not just watching and going, okay, I'm going to see them do everything. And then when I'm ready, I'll do it. Try to do as much as you can with the preceptor by your side safely, of course.

So that then when you do get that time where you're asked, are you ready to be on your own? You feel more confident in those things. And while it may be four weeks, it may also be a little bit longer. The important thing is to communicate. Yeah, I think that's really good advice to communicate because different hospitals might have different orientation programs. Some might be more experienced in helping international nurses or not. And sometimes you find within the same organization that the experience can be different.

Gillian, from your perspective as an international nurse, why would you say the orientation is so important? And what was your experience like?

Oh, my goodness, Tanya, it is the most crucial thing ever. When I think back to when I came from Trinidad and actually I moved to Arizona, everything was different for me first, you know, the culture, the healthcare culture, the culture within the hospital was very different. The equipment was different. There were different medication names. There were so many things like how they contacted the doctors, how they discharged patients, how they admitted patients. So coming from another country into the US, I was able to see both sides and see all the things that were different. And I realized the value of not only the orientation, but a good, thorough orientation as well. Another piece, apart from the actual work, how you care for patients was communication.

That was a huge difference for me as well, Tanya, where naturally I speak very fast. And one of the challenges I had when I went to Arizona was that everyone there, they were unfamiliar with my accent. They had never worked with someone from Trinidad before, and I had to slow down one and enunciate more carefully so that even though I have an accent that is never going to change, that is part of me. I am proud of my accent, but I needed the doctors over the phone to understand me. I needed my patients who English was their second language, so I needed them to understand me as well. So I had to really adjust in the orientation, how I communicated, how I spoke, and, of course, adjust to the practice. So the orientation gave me that time with a preceptor before I was functioning independently and had full responsibility for patient safety. The orientation gave me that time to ask questions of my preceptor, find out what was accepted, what I should do, what I shouldn't do. It really gave me that time to get accustomed to caring from one patient, two patients, three patients. So it gave me the time to acclimate to the numbers of patients, the patient load, the different equipment, the medications, the processes and policies, and the communication differences as well. So the orientation for an international Ness it is crucial to our success and for us to be able to care for patients safely is what I say.

Well, that was very well said, Gillian. And as another immigrant who came from South Africa on the 4 July independence date, I will be here 22 years. I still proudly got my South African accent as well. And I see Arlene in the chat is saying the Jamaican accent is very unique, too. So I think that really adds a whole another layer of complexity. There's so much to learn. It's not just the way the policies and procedures, it's different language, communication styles, technology, cultural difference. There's just so much to learn. And for many international nurses, culturally, it can be hard to be pushing yourself forward and ask questions.

Cornelia, did you find it difficult to ask questions? I know for many nurses in the Philippines you taught to be humble, to be shy, not to be too assertive. What was that like for you? Well, in here because I was told by the nurses that have come here before me that I shouldn't be afraid to ask questions and that they encourage me to ask questions because your license is on the line. You don't make assumptions. So as much as possible, don't be shy. If you don't know something, go ask and make sure you find the right answer. Yeah, very important and very good advice. I'm so glad that you said that.

And I know that aside from Saboo inthe Philippines, Melanes who's a Connetics baby mailingfrom South Korea, Kathryn from Rio, Christine fromPhilippines, Melanes from Philippines, Henry from Kenya.I know.Appreciate that advice and very good tohear that on the Lefora talk show.So Kram is saying preceptorsshould have attended preceptor training.

Honey, can you talk a little bit about preceptor training? Because we're going to talk now about the actual on the job training part of it. Yes. So preceptors in the United States often do go through some sort of preceptor training. It may be a series of online modules, like I mentioned before. It may also be some specific competencies that they're required to demonstrate so that it shows that the nurse is going to be comfortable in being a preceptor. That is a best practice. It is not always something that is required at every single hospital before the nurse becomes a preceptor. I would say it's more and more popular. It's more and more formal. And the idea is that it's not just looking for a nurse who has senior experience. It's also looking for a nurse who has a little bit of that interest in teaching and interest in growing the nurse. Keep in mind that the nurse may have worked for 20 years in a setting, and maybe an excellent nurse may not be the one who's going to be the preceptor. It may be the nurse who's been a nurse for two or three years in that same unit who actually has gone through that training, wants to do that, wants to be a part of growing the team by being a preceptor. Okay. So it sounds to me,

Cornelia, that you had a good experience with your preceptor. Can you talk a little bit more about that? And then, Julian, I'm going to ask you what to do if you don't have a good preceptor. Go ahead,

Cornelia.Let's hear from you first onyour experience with the preceptor. Yeah. I was lucky enough to get a Filipinopreceptor, so there was no language barrier.So if it's just the two of us and Ihave questions, she will answer me in our language.And she actually did more than what's expected of a preceptor for me.So there are interventions that she showed mehow to do because it's way different becauseit's more computer based in here.So she showed me some of the stuff that was not discussed during thetheory based discussion part of the orientation.So, yeah, I was lucky enoughto get a Filipino receptor. Okay.So that can be helpful if you have someonewho comes from the same background or nationality.

Gillian, what happens if you don't get you'renot as lucky as Cornelia, or maybe youget a preceptor that doesn't really understand thedifferences with an international what an international nursesbackground and experience is all about.And we've heard some horror storiesof people getting multiple preceptors.Can you talk a little bit about that,what nurses might experience and what to doif they have issues with their preceptor. Right.So that is something we see coming up from time totime where the nurse that just may not be someone ofyour same background on the unit, and you may not beas fortunate to get that kind of support. Still, it's good to know that a person does not haveto be of your same background to be a good preceptor.But that aside, if you are in a situation where youare thinking that you are not getting what you need, Ithink the first thing to consider is why do you havethe interpretation that you're not getting what you need?So sometimes it may be a personality issuewhere your personality and the preceptors personality justmay not have been the best match, right?It may be a practice issue where the preceptor is simplynot showing you or guiding you in the way you wantto be guided what you need to be shown. Right.So it may be interpersonal. It may be the preceptor skill that piece may comeinto play and determine why one, is it interpersonal oris it what the preceptor is doing or not doing? Right. So that's one that's kind of the assessment piece.Secondly, once you've decided, okay, what exactly isthe real issue here, whether interpersonal or not, I would advise you to make a list.

So if you are going to escalate your concern, which you should, it helps when you have concrete ideas written down that helps guide you when you are speaking to whether it's your educator or your unit manager, it really helps to guide your thoughts so that you are presenting objective, clear information as to why you are not getting the support that you need from your preceptor.So writing things help writing it down and just speaking up. Because when you think about it, at the end of the day, you will be the one who will ultimately be responsible for caring for patients. And if you remain silent, you are not helping you.You are not helping the patients. You're not helping your organization.So the third piece would be you must advocate for yourself, depending on what the arrangement is on your unit, whether you need to make an appointmentwith your manager or simply walk into her office,that would be the next best thing.

Speak with either your educator or your manager.Have your list of items, your list of concerns written down and discuss very clearly, very objectively, what you've observed, what was told to you, what you were able todo, what you've not been able to do, and whatyou want as a learner as a new nurse on this unit and be direct. Ask your educator or manager, how can you help me? Because this is what I need and I want to be able to take good care of my patients when I'm off of orientation.So I would say the first thing is to think why you're feeling the way you're feeling, whether it's interpersonal, and see whether you might need totailor the communication a little bit. Then note whether it's a practice issue, they're just not teaching you or that kind of thing. Write your concerns down and then advocate for yourself with your educator or manager and come out and ask for help.I think those are the main things to do. Great feedback and great advice there, Gillian.

And this is what I love about the Leforatalk show, because if you are watching right now and having an experience that's not as good asCornelia’s with your preceptor, there are very practical tips and pointers of how to address that.So I see we've got Melbourne from Saudi, April from Japan, Nahi from Pakistan.Pamela is here, too.Ramo from the Philippines, lots ofpeople watching all over the world.Thank you for joining us.If you're just joining us now, we are talking about the skills differences that you might experience overseas as opposed to living and working in the United States and talking about how we're right now talking about the on the job training piece.

So Cornelia Julian spoke about writing things down and being very clear and direct in your communication. If there is an issue. One of the biggest problems for many international nurses is that the role and responsibilities of a nurse in America is very different, generally speaking, to that of what you might expect overseas. Can you talk a little bit about that? How is the role of the nurse different here as opposed to, for example, in the Philippines? Well, in here what I felt is you have a bigger responsibility as an RN in the hospital. The doctors and your co nurses, your charge nurses, they expect a lot from you. In the Philippines, it's more of because you handle a lot of patients.

So basically, your job is generally get the vital signs, give the medication, report the patient's complaints, and then tell the doctor in here, it's a lot more. You are expected to do a full assessment of your patient. You are expected to know the medications you're giving to your patients. Thankfully, here in the US, everything is in the computer. Because I remember back home before you give a medication to a patient, you have to know what that medication is for. And back home, if there's an unfamiliar medication, you have to get the drug handbook and check there what's the contraindication, what's it for? But in here, you don't have to look for a drug handbook. There is already information in the computer. You just click on the drug that you're about to give to your patient. Everything is in there, contraindication, right dosage. And if you still have questions, you can easily ask the pharmacist the right dosage to give or right infusion rate for that medication. And in here, the patients look at nurses in a whole different level. Like the respect that you get from your patients and your co workers is a lot different from what I experienced back home. Yeah. Nurses here are very highly valued. As Holly said, the most Noble profession voted the most honorable profession and the most respected profession. But it really nurses. I think have a lot more autonomy and a lot more independence here. I understand,

Cornelia, you were surprised when you first experienced a rapid response in the hospital here. Can you tell us what is surprising and what you learnt? Well, I was actually still in training when I experienced my first rapid response. It was funny to say, but I felt like I was in one of the shows like Grace Anatomy or The Emergency. Sounds like you were on TV. Yeah, because what I saw on TV is what was really happening here, and much even faster. They follow an algorithm. Everybody knows what they're doing. Everybody knows what their role is. So I was like watching my own show in real life. It was fun. Everybody was so efficient. The patient has to be transferred to ICU. It was fast. It was like less than 5 minutes, and the patient was out of the room on his way to ICU. It was fast. I've never experienced that back home. So that was very surprising.

Holly, if a nurse has never experienced a rapid response before, what advice would you have? So, like Cornelia, when I was learning about it, it does seem very tedious, but what you're looking for is that each person's role is defined. So a lot of it comes down to communication. Who's going to be getting the supplies, who's going to be documenting things, who might be administering the medication to the patient. And the algorithm that you're following is based on a lot of different things patient symptoms, what setting the patient is in at that moment, and whether   need to be transferred. That decision is being made based on the very quick evaluation of the patient at the moment and the response to the very quick intervention. So what's really awesome is the nurse doesn't to manage a critical patient alone. And how many times have you been in a situation, regardless of where you work in the world where something happens with your patient, they change very quickly, and you feel scared because you're alone at that moment and you don't know how to get help and how to get enough help and the right help. So in the hospital, the nurse, when they're in that situation, can request a rapid response. A rapid response team responds to that location where that patient is. That alert has been called for, and they begin to work together to stabilize that patient, to transport them, if need be, to a higher Acuity unit and to basically help that nurse.

Problem solved very quickly, and the response times are amazing. What we've seen is that nurses who aren't familiar with rapid response often don't realize they need to go ahead and activate it. And so there's a delay between recognizing that the patient is in a serious state and very sick, and they can't manage it by themselves and activating that rapid response so that the team can get there. So the important thing is, as you learn about how rapid response or something similar works during your orientation, ask questions, understand where those team members come from. Is it respiratory therapy, an ICU nurse, a physician or a nurse practitioner or a PA and what departments they may normally work in or how they're supposed to respond and then how you activate that response in that hospital. Oftentimes it's an overhead Paging system is going to fall out, which we want to minimize that in a hospital, but we know that we have to get the word out. Or it may be that they've designed a system that is remote, that's quieter, but it pays those key people to respond to that location quickly.

And again, you're not alone. You have resources at the touch of a button or a call out. And that's the importance of something like the Lefora talk show, because as Cornelia has experienced, she was surprised by that. So hopefully for everybody who's watching around the world now, you won't be surprised. And you all know what to do. As Holly just said, and Julianne is so much for a nurse to learn, so much for a nurse to learn. But for many nurses coming from some countries and around the world, there might also be a different metric system.

How would a nurse know that and what would they do if that is the case? When you say a metric system, Tanya, referring to units. Yes. That always trips people up sometimes. It's one of the things, though, that we learn about as we prepare to come. We provide those modules. I know Connetics provides modules. AMN Healthcare provides those modules as well, particularly around medications. Of course, you know how important getting your medication doses correct. So it's one of the things that we provide, one of the training modules that we provide to nurses prior to arrival, just so that they are able to manage safely in terms of different units and all of that, so that they know this information before they actually start. Because as you know, medications come in all sorts of different units, grams milligrams, whereas in other countries, milliliters might be used or other types of units. So we do provide I know both of our organizations provide that training beforehand, so that is extremely helpful for when the new starts on the unit so that they can function safely.

Yeah. And I think it's just to know beforehand because there's so much to learn. You don't want to be surprised by something like that. How are high alert medications managed in the US compared with the Philippines or other countries? So high alert medications are identified based on several different risk factors, of course, how fast they act, whether they have reversal options, how dangerous they are in terms of the effect that they could have on a patient. That could be life ending, unfortunately. So one of those would be insulin, which is a very common medication, unfortunately, there are a lot of people who need insulin assistance, but some of those insulin are very rapid acting. Some are slow acting. Regardless of what type they are, nurses are expected to get another nurse to come and witness when they're going to be administering insulin. They Witness, not just I'm pulling up insulin, but I'm going to be giving it because this is the patient's blood sugar and these are the units that are ordered. And here is the insulin type that I'm going to be giving. So what I'm expecting is that 100% of the time you will get that second nurse. Now, what Cornelia is probably experienced is when that second nurse is brought into Witness, there's also an electronic login or a thumbprint or something that the hospital is using to validate that that individual has come in and witnessed that medication, that dosage similar medications are things like Heparin drip.

Again, if a patient has a wrong dose of a Heparin drip, it can kill them. So rather than say if you're scared, they say this is the standard, that you will get another RN to come in with you to check the dosage, to check the order. And if there's any question, don't witness it. Call the physician if you need to get an order. Clarification, have the lab run another lab if you're not sure, of course, with the physician's approval and participation. But high alert medications, each hospital will also usually have their own list. But the common ones are insulin, Heparin, and there are some others that may come up almost on a procedure basis because that hospital has maybe identified that they're using more of a certain type of drug or things like that.

Cornelia, can you think of any other specific medications that you've used recently where you had to get a second nurse involved? Aside from it's usually insulin and Heparin, the computer won't let you give the medication to the patient or start a Heparin drip without a second nurse witnessing the medication being administered inside the patient's room. Because you will scan the medication in here, you have to scan the patient's bracelet and then the medication the computer will pop up. If you're giving the right medication at the right time, then you will have to have the second nurse ready at your side. Tell her she has to get this Heparin drip rate. This is her latest PTT, and then she will have to put in her username and her password before the computer will tell you that you may give the medication now. And with insulin back home, it's usually the first dose of insulin for that patient that you have to be witnessed by a senior nurse or your head nurse. But in here, it's every time you get an insulin. So if your patient needs an insulin, sometimes it's hard for us because the medication administration time is between 08:00 p.m. To 10:00 p.m. For us. Sometimes there is no nurse in the station that you can get. So you have to wait and then she has to put in her biometrics and then you have to tell her how much the patient's insulin is because I have experienced declining witnessing a patient's insulin because I just think she's going to give too much insulin to that patient. I believe the blood sugar was 110 and there was a standing dose to be given of ten units of regular insulin. So I told the nurse, no, I'm not going to witness this. I don't think you have to give the insulin. You have to call the doctor first. So she ended up not giving the insulin because the patient's not about to eat yet and the patient might crash. Okay. So very important. I'm so glad to be speaking about that because it might be something that a nurse from overseas might not be aware of the procedures and how things work in the US in that regard.

And before we move on to technology and I'm just watching the clock, cause the time is going so quickly and we've got so many questions and we're going to be moving on to technology in a few minutes.

And the biggest difference is there but there's a question here from Melvin who is asking a really interesting question. Do you have a checklist as a precept key? I mean, things that you should learn during the preceptorship. This is a question maybe for Harley and Gillian. Any thoughts on that? Yes, actually, most hospitals do provide the preceptor and the preceptee with a checklist of skills or tasks that the precept must accomplish through the orientation. And typically the nurse and the preceptor must both sign off that these things were accomplished and it provides that guidance. So for example, you must do an admission, you must do a discharge, just several different things to validate that by the time you are due to come off of orientation, you have accomplished all of the tasks that we require a registered nurse to be competent with. So yes, the vast majority of hospitals and units do provide that check off list for their orientees. Thank you, Julia.

Sorry, Cornelia. Did you have a checklist when you went through your preceptorship program? Well, they didn't give me like a literal checklist, but I made my own checklist that I need to know the stuff and that's where hospitals might be different. Honey, did you want to jump in? Yeah, just really quickly, Tanya. I mentioned earlier about transitioning a lot of things online. So I've processed a lot of hospitals too. They consider that checklist now to be inside of their computer system in some way. So it may not be a physical piece of paper, it may actually be listed out as modules or things that somebody signing off in a computer for you. So just be prepared that it's not always physical in your hands. And if you wanted something like that to Cornelia's point, you could actually maybe put something down on paper. And to Gillian's previous point, when you have a challenge where you go, you know what? I'm not sure I did understand that. And my preceptor is saying that I'm struggling. Dig in, get the clarity on why that particular milestone isn't something that you're feeling you've accomplished or the preceptor isn't feeling you've accomplished so that you can understand how it might be fixed. But they do have ways of monitoring your progress over that period of your orientation. Thank you, honey. Okay. So, Melvin, I'm glad we could answer your question.

Okay. So we've got two more headings that we still want to do. We're going to talk about technology and culture, and we've got 10 minutes, so we're going to try and get through this real quick, everybody who's watching. And again, welcome to Patrick, Nicholas, Edua, Hannah Bush, Melvin, who asks this question? Leandra miracle richer. So many people watching. April, we already answered that question, April, about how long the Orange preset ship usually lasts. Kyber Bevin, I want to welcome everybody, but we are running out of time. So we're going to talk a little bit about technology. This is usually one of the biggest areas that is a struggle and a challenge for international nurses because in the US, nursing practice is very technology driven.

Cornelia, can you talk a little bit about the differences in technology that you noticed and what that was like for you? Well, the biggest difference is the electronic charting. So the patient's chart is in the computer. You do your assessment in the computer. It's really better because as you do your assessment to the patient, you can document it right inside the patient's room because the computer is there. There's a computer in each patient's room. So you're assessing in real time, documenting it in real time as well. And there are some technologies as well as the vital signs monitoring. So the machine is already connected to the computer. Once you save the vital signs after you get it, it automatically transfers to the computer so the nurse can look at it real time because back home, we have to write it. Write it in the chart. You have to check the chart. The doctor has to check the chart. And in here you can access it as long as you have a computer beside you. Okay. And also the laboratories and stuff like that.

So, Cornelia, did you find that a challenge, though, going from a paper practice to a computer chanting? It was a challenge at first because it's a lot different, but as the time goes by, it's easier than paper charting. Of course. How long did it take you before you got used to it? And obviously, this is just your individual experience. Well, it took me a while because there's a lot it can be overwhelming at first because everything is in there. But it took me maybe the whole orientation period, like a month. And then after a month when I was on my own, maybe one or two weeks before I got really comfortable with the computer charting. Okay. So it takes a while. So anyone who is starting that journey and is not coming from a background of using technology in the way that we use it in the US know that it's going to be a challenge and that it's going to take some time like it did for Cornelia. Go ahead. Sorry. And also because it's a computer charging, there are always changes. But the good thing is the program of our hospital, we have our own program. We call it Health stream. So you will have an email every time there is a new changes that you have to see, you have to make sure you have to see how to charge, let's say pressure ulcers. If there are new changes in the charging, they will send you an email that you have to go into this training. In this program, you have to make sure that you're able to see the new changes and apply it at your work. Okay. So that keeps you up to date.

Gillian, what would you say to a nurse who is sitting overseas now is going to be coming to the US and doesn't have any computer experience, has not done electronic charging at all. So that's a challenge that many of our owners face, where on their home units, it's just not accessible. One of the things that we've tried with our nurses or we are doing with our nurses actually is to ensure that they do have access, if at all possible, to a computer, to a laptop, whether it's personal, whether it's in an Internet cafe, even that you do have some kind of access to a computer. Another thing that we do is we have the nurses do a typing training course, and there are several of those that you can Google and do online, and that teaches you about keyboarding. It really helps to develop your keyboarding skills because one of the things that really challenges the nurse in terms of time on the unit is the keyboarding and manipulating the mouse to document. So that's one of the basic things I would say would be a good idea is to develop your keyboarding skills. Google a typing training course online. Most of them have tests that you can do to test yourself. And if you can get up 25, 30 words per minute, that's good because it helps you to be more comfortable, at least with the keyboard and with documenting. So just basic computer use as much as you can. Daily computer use, improve your keyboarding skills. YouTube videos. There are several online, but it's really difficult to find actual training programs from EMR system manufacturers. So that's a challenge. I think that's a really important piece of advice. And after the show, Gillian and Holly will provide some examples of where you can maybe look at doing some keyboarding practice to help you to get up to speed. If you're not that computer literate, it's very important to do that before you come to the United States, because that really is just practice. So thank you for that.

Gillian Melbourne has a question and this one. Holly, perhaps you can give us some input. And Melvin, keep the questions coming. We love it. Can you just ask what are the different types of EMRs used in the US like for us here in Saudi? We are using Epic system in my facility. Do you have separate training for the electronic medical records, like classroom type, or you just learn it when you are in your preceptor program. So, Melvin, you are at an advantage over some others and that you've seen a system called Epic. It is one of the market leaders here in the United States for acute care, and a lot of other divisions of our health care system are beginning to use Epic. The thing is that Epic and Cerner, which is another common one, are very customizable. What that means is that what you see in Epic in your facility in Saudi may look very different in the United States, whereas the fact that you're using that system on a computer, you're having to type in, you're having to check boxes. You're probably also seeing the part of Epic and some of those other systems that is beneficial. The nurse who is going into document, for instance, an assessment of a patient, and they are doing a head to toe assessment. They go in and they check a box that says abnormal breath sounds.

And then from there, the information that they'll need to follow up with is actually prompted to them. So to Cornelia's point earlier that there's a lot of information in the computer, the way these systems are built actually guides the nurse and what the follow up action and information needs to be and that you would document that accordingly. So, yes, you will have training. It's not always classroom training with a screen and an instructor. Sometimes it's online modules that the facility has developed to show you their version of that system or their requirements. And then the other thing is there is a lot of hands on while you're with your preceptor and you want to take advantage of that. You want to ask those questions. I see Cornelia nodding.

Cornelia, did you want to add anything? Yeah, we spent about like four days of training. We use Cerner in our facility, so we spent about four days. They have like a mock chart in those computers, so we were able to navigate all the parts. So it was easy when you transition on our own and the length of time and days varies. But if you're struggling after whatever training they give you, speak up. If you feel you need more time with the system and be specific in what your challenges are. Yeah. Always good advice. Speak up your preceptors, your educators, your nurse managers are not mind readers. They don't know what's going on in your mind. So you need to speak up. Okay. We've got very few minutes left for the final segment where we look at cultural differences.

Cornelia, what are some of the major cultural differences that you notice between the US and the Philippines? And can you speak specifically about the relationship between nurses and physicians? Because this is really different in the Philippines as opposed to here in the US? Yes, because of the Philippines from the hospital that I used to work there, we have residence. It was a training hospital. So the doctors rely more on the residence and the residents do like the whole body assessment and they report to the attending physician in here. The MDS rely on the RN assessments, especially if they're not in the hospital. So the MDS expect that you give them a report. And if you call an MD, like, they will really answer your call, listen to you, and they will base their orders on what you tell them. So if you have noticed a different bread sounds, let's say, wheezing or a Strider in a patient lungs, you will call the doctor and then the doctor will order either an X-ray or a CT for that patient. So you will really feel that you are, excuse me, part of the team. So you will really feel the collaboration of the nurse and an MD, and then also when the MD do his rounds, a part of his documentation will always be did round discussed with RN, blah, blah, blah. Yeah. And it's interesting when you said you will feel the difference because I think there is a feeling that your role is so important and integral to the team, and that really is one of the biggest cultural differences, I think. Julian, we spoke a lot about speaking up and asking questions.

Can you talk a little bit about assertiveness, how important that is for an international nurse and how difficult that is for an international nurse? Yeah, it is very difficult just depending on the culture that you're coming from. Right. It just may not be something that you're accustomed to doing in your setting. It may be discouraged, actually. But here the culture in the US is so different. It's one where communicativeness is valued. So, for example, if a nurse is new and he or she's a bit shy, they're a little bit nervous and you're not speaking much. Others can assume or may assume that one, you don't know what you're doing, you don't know anything at all, or they may think you're a little standoffish, that you don't want to communicate with them. And that might cause some people to feel offended, actually. So the culture really values communicativeness one and assertiveness. It is respected here when you are assertive. And when I say assertive, speaking respectfully. So assertiveness doesn't mean shouting or that kind of behavior. Right. But just not being afraid to speak up, to share your thoughts clearly, politely, that kind of thing. So it's those two things that are really valued, really important in this culture. It could be so different from other cultures. Yeah. And I think really important to distinguish, as you've done, the difference between being assertive and aggressive. Yes, those are two different things in the US. The culture, as you said, values assertiveness. That doesn't mean to say it's about being aggressive.

Final question. Sorry, I just wanted to see someone had a comment here, so I just wanted to see Melbourne. Thank you guys for this lecture. I think it's very important for US foreign nurses who aims to work there to learn all these stuff. And I agree with you 100%, Melvin. So final question for Holly, for me. And we're talking here from a cultural difference perspective. Many nurses don't kind of understand the nurse hierarchy, how things work. So we've spoken about speaking up. We've spoken about the value put on a nurse to be as a team member.

Cornelia spoke about that feeling that you have in the US, that it's just different. You have a voice in the US system. Can you speak, Holly, just for a minute or two about the nurse hierarchies that exist in the United States and how to navigate that as an international nurse, because sometimes you don't you say speak up to who and how. I think I'll talk first from a patient perspective really quickly, which is when it comes to the fact that you're responsible for a patient, it doesn't matter whether you feel that your nurse manager or your assistant nurse manager or the physician might not agree with you. You are the closest clinician professional to that patient. And so if you notice something that seems relevant and you choose not to speak up because you feel like, well, maybe the senior nurse should be the one to identify that.

Maybe the senior nurse is the one who's supposed to say something to the doctor or where you come from, maybe you're not allowed to say something to the physician directly. Maybe you have to take that to a senior nurse who then takes that to the physician. So whatever that hierarchy is where you come from, here we have what I'll call a much flatter structure. The expectation is that regardless of what title you hold, ultimately each member of the team is responsible for bringing up or speaking up the things that they see happening with that patient and trying to find ways to collaboratively address it within their scope. A good example of this is if a nursing assistant who doesn't even hold a professional license like you do, comes to you and says, listen, I see that this patient you're getting ready to give insulin and they don't want to eat their breakfast. And I'm really concerned if you as a nurse. So you know what? That's not your place to tell me that I'm the one who needs to be responsible.

Then in this culture, that would be considered very inappropriate. We want to honor people that speak up on behalf of the patient and take that information into account. That's a hierarchy for patient care and a way of flattening the hierarchy to be able to get the information from all of the team members who are responsible for that patient. That includes the person who delivers their trade to their room for breakfast. If they see something, we want them to say something, and we want them to say it preferably to the nurse. But we also want the nurse to validate that. We appreciate you bringing that information to us. You're not lower in terms of the importance of what you are doing to try and protect that patient. When it comes to concerns, there's also a hierarchy of what we call a chain of command. So that's the other piece. And with that, if you have a challenge or a concern, you would want to go to the next level up in the chain of command. So, for instance, I would want to go perhaps to my charge nurse first or my assistant nurse manager. Then maybe that next step might be the nurse manager, then maybe that might be the Department director. And then if I can't get what I need as I go through each of those levels, then I may want to reach higher. If instead I go first to the director of the Department and I say my preceptor is not giving me what I need. Well, we told you we think that you need to speak up, but unfortunately, you've not gone to the person that is most likely to be able to help you. And so if it goes above or at the wrong level of that chain of command, it may actually take more time and complicate things to get it addressed. And the manager may say or the director may say to you, who have you addressed this with first? Did you follow the chain of command and go through that process, or are you coming to me before you've done that?

Well, we're going to finish off on that note, which is great Sage advice, because I think we've shared so many things on the show today about things that nurses just might not know. That chain of command, the hierarchy of nurses and the value of speaking up, the importance of rapid response and high alert medications, and so much great content and so much valuable information shared with nurses around the world. And I want to thank our panel. Cornelia, thank you so much for joining us and for sharing your experience to Gillian, who is an international nurse herself, who brought her own experience, as well as that from AMN and how to help a nurse to make a smooth transition. And highly from kinetics adding that excellent, great perspective and sharing so much greater advice and tips.

So before we finish off everybody, I just want to share about some upcoming shows. We have the Connetics College which was launched on Monday. We're very excited about this. This is a live show for global nurses education. It is free for everybody. Very good education and we have shows coming on on IELTS and NCLEX and lots more shows on different topics coming up on the Connetics College. We also have every week on a Friday onwards and upwards which is our shows on different topics. On the 17th we have state side where we talk about living and working in Pennsylvania. On the 24th we have our immigration Q and a and every week we have topics that are very interesting and important for global nurses. This is free information for you and next month for the Lefora talk show we will be talking about the five biggest surprises or lessons that nurses learned when they arrived in the United States and how to navigate that. So lots more information coming up and now is a great time. If you have not yet passed your inquiries to do so. There are many jobs all over the United States and we look forward to seeing you in America.

Thank everybody. Thank you for joining us. See you next month. Thank you. Thank you. Bye.