International travel nursing to the USA is a challenging but rewarding experience. If you’re considering this, check out this guide for foreign nurses to answer some of the most common questions about nursing and healthcare in the US.
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International Travel Nursing in the United States
In the United States, nursing practice is regulated by a State Board of Nursing in each respective state. For example, here is the website for the North Dakota Board of Nursing. To go to any state’s website, simply click on this map on this page, then click “visit member website”
There is an organization that is over all of the state boards of nursing, and it is called the National Council of State Boards of Nursing. This is actually the organization that writes the NCLEX examination, which is the test nurses must pass to practice after completing nursing school in the US.
Each respective state has its own Nurse Practice Act. The Nurse Practice Act in your state is a law. You are required, by law, to uphold this as you practice nursing.
Here is a sample; the Illinois Nurse Practice Act.
A Nurse Practice Act outlines:
- Qualifications that must be met to obtain a license
- Acceptable titles, so people are not calling themselves a nurse to the public when they are not in fact a nurse (which would be deceptive)
- Your scope of practice – what you are legally allowed to do as a nurse
- What happens if you violate the law – disciplinary practices, which includes things like nurses using illegal substances/working impaired/diverting drugs, neglect, abandonment, or getting convicted of other felonies and what that means for your nursing license
You need to follow your state practice act! If you don’t, you could go under disciplinary proceedings and possibly lose your license.
Essentially, the purpose of having nursing licenses and regulating them is to protect the public. It sets minimal qualifications and competencies for people who can legally call themselves a “registered nurse”.
You will initially get a license after submitting required paperwork. Once you are licensed, it’s not permanent. You will be required to renew your license on a routine basis.
Important Questions to Ask About International Travel Nursing
If you’re looking at working in a specific state, it’s really important to know the answers to some very important questions. The answers to these vary depending upon the state you’re going to work in, so it’s important to go to that state board of nursing website to find the answers.
- What is the process for obtaining your license in that state?
- How often do you need to renew your license?
- What are the specific requirements to renew? (Continuing education credits, practice hours, both, or other requirements)
- What could cause you to lose your license, get your license suspended, or issue fines?
The Nurse Licensure Compact (NLC)
You can get a nursing license in one state, or there are different states that are part of what’s called the Nurse Licensure Compact (NLC). Other names for this include multistate licensing or mutual recognition. This means that if you get a license in a participating state, then you would be able to work in other states who also participate in the Compact without going through all the paperwork and starting at step one to get a license in a different state.
According to the NCSBN, “The NLC increases access to care while maintaining public protection at the state level. Under the NLC, nurses can practice in other NLC states, without having to obtain additional licenses” (source).
Healthcare in the United States
Our healthcare system in the US is very complex and constantly changing. The bedside nurses, especially in hospitals, work closely with other members of the healthcare team (like social workers and case managers) to navigate this together with their patients. Chances are, the set up of the healthcare system in the US is vastly different from your country of origin. So, let’s go through a few basics on healthcare in the US.
Patients may have private insurance plans, ones from the government (Medicare/Medicaid), or a combination of both.
What is Health Insurance?
Basically the individual pays for a plan (often a monthly fee). For many, this plan is provided by their employer and the monthly fee is taken from their paycheck. When the person goes to the doctor, they provide their proof of insurance and then the cost of the visit is occasionally completely paid for by the insurance agency, part, or none of it is. The individual may also need to pay a “copay” which is a small fee per visit (often $10-20 USD) as well.
This can get pretty dicey when a patient has a visit or procedure done and the insurance agency says it isn’t necessary. They may refuse to pay for it or say certain medical procedures cannot be done without their approval. You may hear terms like “pre-authorizations” or “pre-auths” or patients asking if insurance will “cover” something.
Because healthcare is incredibly expensive in the US, you might get a lot of questions about what’s covered and what’s not. If you’re working in acute care/in a hospital as a staff nurse, you often are not told or aware of the actual cost of various interventions, procedures, medications, and so forth. That would be a good time to call your case manager or financial services department at the organization so they can field those questions.
Important Organizations to Know for International Nurses
Here are some very common organizations in the US that you’ll learn about soon. There certainly are more, but below are the major players.
Occupational Safety & Health Administration (OSHA) is a division of the US Department of Labor and its mission is to make sure you’ve got a safe work environment. You’ll probably have to complete educational activities wherever you work that are OSHA requirements. (For example, the Bloodborne Pathogens Standard is a common one).
HIPAA is a big deal. The Dept. of Health and Human Services enacted something called the Health Insurance Portability and Accountability Act (HIPAA) in 1996. The act has a lot of info in it, but the biggest things that you’ll quickly learn about is patient privacy. This is incredibly detailed and important!
The Joint Commission is another major one. It’s a private company, but it offers “accreditation” or their stamp of approval to say that the hospital meets certain standards. While it’s voluntary, a lot of organizations get this accreditation out of necessity because some private and governmental insurance agencies won’t reimburse for care unless they are accredited.
Magnet Status is an accreditation granted by the American Nurses Credentialing Center (ANCC) and it’s a pretty big deal. It’s a large and expensive undertaking for a hospital to go through, but once a hospital has its Magnet Designation, it’s a pretty big deal. Essentially, this is an accreditation for hospitals saying they’ve got really great nursing care that only a small percentage of hospitals have achieved (as of today only about 8% of hospitals have it).
International Travel Nurses Working in the Hospital
Working in a hospital in the US might look a bit different than in your country of origin. Here are some common areas that may differ.
Delegation
In the US, we often work together on the same with unlicensed assistive personnel (UAP). These are individuals who help with the activities of daily living (ADLs) a patient has, but is not licensed to provide nursing care. You can’t delegate something that requires nursing assessment, skill, or judgement. Your state practice act and your hospital’s policies and procedures should outline specifically what you can and cannot delegate.
Providers
Generally speaking, the word “provider” in healthcare can mean anyone providing healthcare services. However, when you’re in the hospital and people refer to someone as “the provider,” they’re typically referring to the physician and/or a nurse practitioner (NP) or physician’s assistant (PA).
Many members of the healthcare team hold doctorate degrees (pharmacists and physical therapists, for example) and NP/PA can complete many tasks that a physician would, so using the word “doctor” can quickly get confusing. As the nurse, you’ll often need to speak with your patient’s provider to discuss the plan of care and get various orders. The attending physician and his or her team (that may or may not consist of NPs/PAs) would be who you go to for these needs.
Physicians round once per day, and expect you to monitor the patient, ask questions, summarize what’s happened, and follow-up with them as needed in between their rounding.
It’s considered normal to ask and question decisions in a respectful manner. Some countries do not encourage respectful inquiry, however in the US it is expected for nurses to bring their critical thinking, questions, etc. to the physician and the medical team.
Additionally, medical teams commonly work in groups. After hours (often after 5:00 pm), one member of the team is “on-call” to field any questions or needs overnight to allow everyone else to rest. They take turns being “on-call” to spread out that responsibility evenly. Therefore, if you’re calling about a need for your patient after hours, you’ll always want to begin the call by asking, “I’m calling about ___________ in room __________. Are you familiar with this patient?”
Doing so would not be considered rude or inappropriate; it is actually helpful. If the physician is familiar with the patient, you would not need to give near as much detail as you would if the on-call physician is hearing about them for the first time.
Talking Points for Tough Moments
As you start out in a new country (and possibly an entirely new language), you may find yourself caring for patients who speak very quickly, or say things you’ve never heard before. If you don’t know what he or she means, ask! It’s really important, especially in healthcare in terms of safety, to know what someone means when they say something. It will not be viewed as pushy or rude to clarify what someone means. Just make sure you ask in a kind and respectful manner.
Helpful talking points for confusing moments:
- “I’m sorry, I have never heard that term before. What do you mean by that?”
- “I’m not sure what you mean by that”
- “I’m not familiar with those words, can you explain what you mean?”
If you’re worried your patient is doubting your nursing capabilities because your English isn’t as fast as they’re used to, you can always discuss where you’re from, how long you’ve been a nurse, and what it’s like being a nurse in another country. At the end of the day, what matters most is that you’re providing safe and competent care.
And if you’re still mastering English, confide in your colleagues! Let them know you are working on getting better and the language. Most people are happy to help, but would wait for someone to ask for help rather than assuming you need it. Practice during break times, ask questions, and develop rapport with them so you can ask them when you hear new terms for the first time. It’s helpful to know you’ve got someone you can go to with needs!
Learning About Your Organization
Each healthcare organization runs differently. Some are stand-alone organizations, where the entire organization is within one building. However, many are now part of larger corporations with many locations across different regions.
As you familiarize yourself with the organization, things you want to ensure you understand are:
- The attendance policy
- How to access and review their policies and procedures
- How to request time off, personal days, and vacation
- How to call in sick / appropriately address unplanned time off
- FMLA; the Family and Medical Leave Act process at your facility – an act that guarantees time off to deal with very specific circumstances so you don’t lose your job
Learn About the Local Population
I highly recommend learning about local culture because it varies widely across the country. If you’re working in the rural Midwest and dealing with a primary patient population of farmers, that would be a very different demographic than a large coastal urban area. The Northeastern US has a different vibe than the Southeast. The differences are too much to go into here, but it’s helpful to be aware of what’s important to the locals of the area you’re moving into.
You’ve Got This!
Deciding to do international travel nursing is a big decision, but it can be incredibly rewarding. As a nurse, you have a personal responsibility to speak up and ask questions. Make sure you have an open mind as you embark on this adventure and maintain a sense of personal responsibility to own your own practice and ask questions if you don’t understand something.
In the US, healthcare and nursing are highly regulated. Therefore, it’s important to be safe at every turn and understand the expectations of your state board of nursing and the healthcare organization you’re employed by. Regardless of the location, patient safety will always be the top priority!
It will be a lot to learn at first, but the autonomy that comes with working in the US as a valued member of the healthcare team AND member of the most trusted profession is so worthwhile, fulfilling, and enjoying.
More Resources for International Travel Nursing
- How Do I Become a Nurse?
- Institute for Safe Medication Practices – List of Confusing Drug Names
- National Council of State Boards of Nursing
- Nursing Licensure Compact
- American Nurses Association Code of Ethics – you can download the ebook for free
- Institute for Safe Medication Practices – List of Error-Prone Abbreviations
- Family & Medical Leave Act (FMLA)
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