Cross Border Training

I once believed all nursing was created equal…


As a Canadian nurse, we have been mandated that all new graduate nurses after the year 2000 must be educated with a Bachelors Degree (BSN) except in some areas of Quebec. In addition to holding a BSN, to work in speciality areas in BC, such as the ED (OR, renal, peri-natal, ICU), specialty education is promoted and even paid for! (An effort to reduce the shortages in specialty areas). Currently in the USA, associate level nursing is still accepted, although there is a push by employers to promote BSN nursing. For one employer I have encountered, the goal is to have 70% of nurses at the BSN level by 2020…ONLY 70%!

What I have discovered while working in the USA is many nurses DO have their BSN; however, this level of education is preferred not mandatory and many of the nurses in the USA ED’s remain at the Associates level. In addition, the ED specialty is a certification by exam with no formal educational process to guide the learning. What is typically required to work in this specialty area is a preceptorship with an experienced mentor.

I believe if you give this some thought, you can see the potential for flaws from anything related to “cultural teaching” i.e.“this is how we do it here” and “experiential teaching” i.e. “this is all I know how to teach”. My thoughts also lean towards, “what is the evidence based practice being used to teach?”. Hence, as a Canadian nurse I am skeptical of this educational process. In my ED specialty program, I was taught a very specific assessment framework and provided with a solid theory foundation, I have yet to see anyone in the USA really follow this framework (with the exception of in a “code”). My practice has been challenged and my assumptions questioned…

So, if you are a Canadian nurse planning to travel to the USA, your education credentials should be no problem!

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Another eye opening difference to the educational requirements of working in the USA was the need or demand for American Heart Association (AHA) ACLS or BLS certifications. Prior to leaving Canada, I ensured my credentials were up to date and that I would not need to renew my ACLS or BLS in the near future, I did this for a couple of reason to include time and money. Little did I know that hospitals in the USA, might not recognize the Canadian Heart and Stroke Foundation as a reputable source for ACLS/BLS information and teaching!

My first assignment in Washington required me to renew my BLS to reflect the AHA, my second assignment was OK with my credentials and my third assignment required me to renew my ACLS, this boggled my mind. Where exactly did these facilities come up with these requirements? Is there an exchange rate on chest compression between Canadian and American CPR? As a Canadian nurse when I count my chest compressions/ventilation ratio I must be using a different set of numbers…1eh, 2eh, 3eh verses 1 ohrah!, 2 ohrah!…definitely different! So what’s really the difference, nothing! The Canadian Heart and Stroke Foundation gathers their information from the same place as the AHA, in fact all the literature, videos and testing are EXACTLY the same AND all the foundations (USA or CAN) base their information on a collective evidence based knowledge approved by the World Health Organization (WHO).

So, in order to be approved for employment in the USA be sure your credentials state AHA or you will be taking the courses over again, if for no other reason than to spend money on a new logo!

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I can’t stay…

The first time I heard a patient tell me “I can’t stay…” broke my heart! As a new nurse to the USA, I didn’t know this would be a regular occurrence…I’ve heard these words uttered in Canada but never for this reason!

As my patient is being wheeled from triage in a wheelchair, I noticed the very distinct facial droop that represented a potential stroke (CVA). The overhead paging system confirmed my thoughts as it rang out “stroke alert”.


A group of efficient nurses, doctors and techs helped me settle the patient, obtain all the necessary data, and get the diagnostic labs, EKG, monitor, and CT initiated.

This patient was physically and emotionally healthy with a supportive family. They were from an average middle-class background and while at work he/she began to have symptoms of facial droop and slurred speech. The symptoms were concerning but the CT did not confirm a CVA. The Doctor wished to admit the patient for observation. Admission is not unusual to observe for progressing symptoms and to follow up with additional CT scans or MRI. BUT, the patient refused…

“I can’t stay…I can’t AFFORD to be here…” and the patient signed an AMA (against medical advice) and left, knowing the potential of risk for life and limb!

Why, why would they go?

Did they understand they could die…yes! Did they understand the CVA could still be present and cause debilitating paralysis…yes!

But, money trumps everything…

Here in the USA, I have learned that having insurance does not always mean being able to afford healthcare. Premiums are high, deductibles are outrageous and many people still don’t have insurance. These insurance issues cause patients to leave the ED because of financial choices verses staying for health reasons. I am far from an expert on the healthcare system here and I have lots to learn BUT I do know the patients and speak from experience, this story is not an isolated to one…every time I hear a patient say “I can’t afford to stay…” I know they are making incredibly difficult choices between health and money, a struggle no one should have to face.



disclaimer: person, place and time have been left out of this story to prevent identification and preserve HIPPA. This story has been told in general terms to avoid identification and is intended to remain a personal experience.