A Canadian Nurse in the USA
After moving from Toronto to Texas, a nurse encounters culture shock, but ends up embracing the new system.
I was so naive about new employee orientations at hospitals in the USA that I failed to bring my Social Security card to my first one, unaware that I would have to record my number multiple times on the stacks of forms I filled out. The orientation lasted a full week and included sitting through mind-numbing, eye-glazing presentations on corporate ethics, workplace safety, security and other topics.
At one point a human resources employee ushered a few of the orientees to the hospital’s marketing department. Marketing? What in the world did that have to do with healthcare?
A lot, as it turned out. There was a waiting list for admission to a rehabilitation floor that specialized in head and spinal cord injuries, and some of the prospective patients lived overseas. Confirming the ability of these patients to pay consumed much of the marketing staff’s time and energy. They also worked diligently to promote and publicize the hospital through various advertising campaigns and raise its profile in the community. "What a waste of time," I thought.
But this aspect of American healthcare was only the beginning of the ongoing culture shock that myself and other Canadian nurses experience. Adjusting to a different healthcare system can be an exciting, challenging and sometimes frustrating adventure.
The Immigration Process
There are probably as many reasons nurses move to the USA as there are individual nurses. In my case, I enjoyed working at a world-class teaching hospital in Toronto, Canada, but the stress, lack of options and high cost of living in Canada’s largest city were wearing me down. There were few job openings and little opportunity for even lateral movement, despite the fact that I had worked for 14 years as an RN. I had also hit midlife and simply wanted a change of scene and warmer weather.
One of my children had moved to Austin, Texas, and after a visit I decided to relocate. I made my move in 1992 and wasn’t disappointed. After 15 years here I have been able to add experience as an investigator for the State Nursing Board and as a legal nurse consultant to my resume.
Under the North American Free Trade Agreement (NAFTA), professionals from Canada, including nurses, can obtain work visas that are usually good for one year. Nurses are recruited directly by hospitals, at job fairs or by international recruitment firms. Many nurses are offered incentives such as sign-on bonuses, travel expenses and relocation costs, as well as scholarships for continuing education.
The Commission on Graduates of Foreign Nursing Schools (CGFNS) screens foreign nurses for education, licensure in their home country, ability to pass the NCLEX exam and proficiency in English, though this is rarely an issue for Canadians, except for some nurses from the French-speaking Quebec province. A few states waive the NCLEX.
The immigration process includes getting a valid nursing license in a U.S. state, securing a job offer from a U.S. employer, and applying for a Social Security number. A nurse can also accept a permanent job offer from an employer, leading to a green card (actually pale pink) that allows permanent residence.
How It Works in Canada
On my first day in the unit at an American hospital, I watched in surprise as my preceptor opened a sterile tray, peeled off a sticker, and placed it on a billing sheet in the patient’s chart. "How mercenary," was my first thought. I soon realized that the method of delivering and paying for healthcare in the United States is very different from Canada’s approach.
Misconceptions about Canada’s "socialized medicine" are rampant in the USA. In Canada, almost no one has private insurance because the government healthcare system covers everyone, “womb to tomb.” Beginning in the 1960s, each of Canada’s 10 provinces introduced single-payer universal health coverage. Though the plans vary from province to province, there is reciprocity among them, so if you need care while visiting another province, your home province will pay.
While the downside of this system may include delays for elective surgery, waits for some diagnostic tests, including CT scans and MRIs, and occasionally having to travel for treatment, there is also an upside. Most Canadians are happy with their healthcare system. Families with children don’t have to worry about the cost of treatment, no one has to field calls from creditors, and the threat of bankruptcy due to medical bills is nonexistent. (Many of the textbooks in my nursing program in Canada were American. We used to laugh smugly when they mentioned the cost of care as a stressor for those who were ill.)
After a doctor treats a patient, he or she bills the government, which then pays the physician. Patients are not billed. All prescription drugs for those over 65 are free, although significantly higher Canadian taxes help pay for them. However, certain treatments aren’t covered: Glasses and eye exams, hearing aids and tests, dental care and most plastic surgery fall into this category. Doctors like the system because they are paid promptly and a physician’s staff doesn’t have to bill patients, which cuts administrative costs.
The government sets fees for doctors’ services and renegotiates them periodically. Hospitals are given budgets that are reset every few years. Every Canadian has a health card but can choose his or her own physician and change doctors at will.
Some Canadians have extra insurance through their employers, but it simply pays for a few frills, such as an upgrade from a semi-private to a private hospital room. This is somewhat meaningless, however, since a private room may not always be available. Patients who need them because they are in isolation or terminally ill get them whether they have extra insurance or not.
Why the American System Is Complicated
Foreign nurses find it incredible that Americans usually obtain their health insurance through employers, meaning that any job switch can mean changes in coverage. Some Americans may hesitate to change employment since it can jeopardize their family’s coverage. Others can’t get insurance due to pre-existing conditions.
Just trying to navigate and understand the hundreds of different healthcare plans available, each with its own deductibles, co-payments and rising premiums, can be a surreal experience. The shifting sands of managed care fail to provide much continuity for the average patient. It’s bad enough for the young and healthy; I can’t imagine dealing with healthcare issues at age 84, possibly with failing sight and hearing. Yes, I’ll have Medicare — if it still exists — but there will be errors, omissions, phone calls and paperwork relating to gap insurance, which most seniors need to supplement Medicare.
Canadian nurses working in the USA are sometimes shocked when they encounter patients whose diseases have progressed to dangerous stages because they didn’t get preventative care, children who haven’t been immunized, and seniors who can’t afford prescribed drugs.
The extent to which healthcare, from drugs to clinics to doctors, is hyped and advertised in the USA is also a revelation to foreign nurses. It can be difficult to assess the quality of care offered in these glowing advertisements and it is treated as a commodity, bought and sold like cars or refrigerators.
Adjusting to Nursing in a Different Culture
On a practical level, my orientation to the unit where I first worked was conducted by an LVN. In Canada, most hospitals are staffed by RNs. While there are also registered practical nurses in Canada, usually called RPNs, their professional education lasts two years and may be more comprehensive than American LVN or LPN programs. Generally, there are fewer CNAs in Canadian hospitals, except in chronic care facilities.
Like most of the world, Canada uses the metric system, but I soon adjusted to 98.6 F, rather than 37 C, as a normal body temperature. Values for certain lab tests are sometimes expressed differently, too, and some drugs and equipment have different names in the USA.
On a more superficial level, American hospitals often try to imitate a hotel environment, with marble lobbies, expensive floral arrangements, even fountains. Decorator veneer may mask the facility’s true function, but surfaces can lie — the hospital may be understaffed and rife with infection. In Canada, as in many parts of the world, hospitals are less fancy, often with drab institutional green walls. But in Toronto, for instance, many hospitals have hand-washing stations in their lobbies that everyone entering and leaving the premises is encouraged to use.
“What I found hardest to get used to,” says Jan, an ICU nurse originally from Alberta, Canada, “is that in many American hospitals, the people formerly known as patients are now called ‘customers,’ ‘clients’ or even ‘guests.’ There are two problems with this. If the patient is a customer, what does that make the nurse? To complete the analogy, the nurse must be seen as a ‘service’ person, such as a server, salesperson or maid, rather than as a professional. Secondly, you know the corollary to calling people customers — something about always being right!”
There is also a more adversarial atmosphere in American healthcare than elsewhere, caused by factors that include high costs and expectations fed by the media. The specter of malpractice litigation looms over every encounter and lawsuits are common. Nurses are generally viewed by management as mere cogs in the vast, profit-generating machine that healthcare corporations and managed care have become.
In Canada, the nurse manager on my unit shared administrative problems with us. Staff meetings included discussion about the budget the hospital administration had given her to work with. If there weren’t enough stethoscopes or heated blankets to go around, at least we knew the rationale for the shortage. It also built solidarity, since we felt like valued and informed members of the team.
The Benefits of Nursing in the USA
But there are far more educational opportunities for nurses in the USA than elsewhere and, because the demand is so high, they can change jobs with relative ease.
“You can more or less choose your own career path,” says Karen, who moved from Toronto to a hospital in Houston and loves it. “The financial reimbursement is much better, and if you’re willing to be flexible, the sky is the limit.”
In Toronto, she had only been able to find part-time work. Some Canadian nurses actually reside in Canada but cross the border to work each day, most significantly in border states like Michigan or Maine. Some nurses in Windsor, Ontario, for instance, work in Detroit, a short commute across the border via a tunnel beneath the Detroit River.
Healthcare issues are important in every culture. Most Canadian nurses appreciate the opportunity to work in the United States and easily acclimate to the changes involved. They realize that state-of-the-art care is available here — for those with good insurance coverage — and delivering it is one advantage to working in the USA. Such healthcare innovations may be slower to reach north of the border, a fact sometimes experienced on visits home. To be objective, culture shock for Canadian nurses can work both ways!
Diane Barnet is an RN and a legal nurse consultant. She has written for the Los Angeles Times, Backpacker and American Careers. Her book, What You Need to Know About Hospitals, was published by Crossing Press in 1998.
This article is from workingnurse.com.