Nursin' USA - Lessons from across the pond

31 January, 2010

In the first of a new series looking at the differences between nursing in the UK and the US, Sara Morgan talks about tricky hospital corners.

When I first moved to the UK and began practicing as a nurse here, I knew that adjustments would have to be made.

First, I had to relearn my mother tongue because, as George Bernard Shaw noted, “England and America are two countries separated by a common language”. Every drug had a different name on this side of the Atlantic, abbreviations were changed (why is nitroglycerin GTN in the UK and NTG in the US?) and my spelling, which had always been stellar, was suddenly terrible. Recognize these: pediatrics, esophagus and hemaglobin?

While my left brain was struggling with getting my words and pronunciation right, my left brain was coming to grips with all of the different numbers I was encountering. I was surprised that the UK still weighed people in stones as I was quite sure that both pounds and kilograms were readily available. Most lab values had radically changed as well. A normal blood glucose in the US is between 80 and 120 mg/dL. Change the units, though, and all of a sudden, normal becomes 4 to 7 mmol/L here in the UK.

But my biggest hurdle in adjusting to work here came from a surprising source: hospital corners.

You are probably reading this thinking ”What’s the problem? Hospital corners are easy to do and if you weren’t taught how to do them at home, weren’t you taught during your very first hospital placement in nursing school?”And that’s where you would have identified a key difference between American and British healthcare: the fitted sheet.

In my American hospital, we had fitted sheets to go on mattresses and flat sheets to be tucked over patients with their blankets. When I realized that my new English hospital didn’t have any fitted sheets, I suggested that purchasing some might save a lot of time for nurses when they make beds. Additionally, since fitted sheets don’t slide loose, nurses aren’t constantly trying to pull out wrinkles that have formed underneath patients who do a lot of tossing and turning. The explanation I received was this: all sheets were pressed after laundering and fitted sheets would not pass through the rollers of the press. Since I had no suggestions for how to get around this requirement, I was left wondering why sheets needed to be pressed in the first place. I admit that Americans are known for being casual in both dress and attitudes, but in this case, our “casual” and therefore unpressed hospital sheets seemed to be a benefit to both nurses and patients.

Fitted sheets were not unique to my hospital, either. Back in nursing school, in between learning to measure blood pressures and how to put on sterile gloves, we were shown how to make hospital corners. Once. And the professor even prefaced the lesson by saying “We will be showing you how to make hospital corners today, but only for historical reasons. You’ll never have to do them in practice.” We all watched attentively, laughed at how old-fashioned it seemed (right up there with wearing nursing caps) and then promptly forgot all about it.

“We will be showing you how to make hospital corners today, but only for historical reasons. You’ll never have to do them in practice.”

This lesson came back to haunt me. I was fine asking my fellow English nurses to show me how to use an unfamiliar type of ECG machine, or having to look up drug names in the BNF, but my pride was at stake when it came to bed making. I simply couldn’t ask anyone how to make hospital corners. It was too basic a skill, almost as bad as asking someone to show me how to feel a pulse. So I slyly watched the other nurses around me, and tried to pick up their techniques. If I was helping someone to make a bed, I made sure I was ready with the blankets and top sheet, while the other person tightly tucked in the corners. But for all of my observing, copying and practice, I still can’t make a proper hospital corner. The edges are loose, the creases saggy and the sheet pulls free at the slightest hint of tension.

So, to any of my British patients who have woken in bed to find bunches of fabric gathered under their shoulders, or the bottom of their sheet wrapped around an ankle, I offer my apologies. This American can convert her weight into stone and spell colour with an extra ‘u’, but she simply cannot master the art of the hospital corner.

About Sara Morgan

Sara Morgan trained and practiced as a nurse in the United States before coming to work in the UK. She has worked as both a nurse practitioner and as a lead nurse on the Productive Ward initiative.

Readers' comments (27)

Anonymous | 31-Jan-2010 10:30 am
Nice. I am British but I trained in the United States. I lived over there for a total of 20 years before I came back to the UK. Old fashioned and backward are understatements. The backwardness really makes things hard for the nurses here.

I was taken by surprise by the hospital gowns here in the UK. They have no snaps on the shoulders and staff have to take IV tubing out of pumps and weed the entire set up through the sleeves when changing a gown. Or they have to disconnect the IV. This leads to care assistants pulling IV lines out of pumps without clamping the line, even after being told that they shouldn't be touching the things. Why don't we just have snaps on the sleeves?

The enitre 30 bed ward has two phones in bad locations away from the patients. Over there each nurse had hospital issued mobile phones strapped to their uniforms so that the ward clerk could just transfer a call straight to the individual. If I was with a poorly patient and needed to call a medic, I didn't actually have to leave the patient's side to go and que up by the far away phone as I do here. If I was with a patient and needed help I rang another nurse rather than leave the patient to look for another member of staff.

We had computers that we entered obs and intake and output values into and it totaled things and gave a nice updated print out. Our handovers were updated daily by computers and ward clerks who were trained to make sure all the information was needed was there. The information that you needed to do your job and no about your patients was so much clearer and organised.

Over here I have to short hand jot all the information I am getting for 20 patients in report. IF my hand cannot keep up with the speaker, I miss crucial information. Pharmacy immediately recieved orders for any new IV drugs that were ordered via computer by the doctor and mixed the IV meds and tubed them up to us ready to go over there.

It takes me two hours to order from pharmacy, chase IV drugs and mix them myself just for the IV's on one drug round in the NHS. No wonder the patients here don't see their nurse.

And this was in the US 15 years ago.

I am heading back over there so I guess it is time for reverse culture shock to rear it's ugly head.
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Anna Lincoln | 31-Jan-2010 10:34 am
Wow. I never would have thought that any thing so ridiculous, time wasting and screwed up as productive ward would come from an American.

The problems on these wards are lack of staff and poor design of the wards themselves. No amount of cupboard tidying and fall charts to colour in are going to solve those problems. It just makes it worse.
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Anonymous | 31-Jan-2010 5:16 pm
I am a Canadian trained nurse (Graduated in 1982, who had the opportunity to work 3 years recently in England: both in the private and public hospitals. At first it was challenging with the drug names and the terminology, as there were differences in the spelling the pronunciation of words, At first it was difficult to even understand what you were saying but now I am proficient in understanding and even chuckle when I hear the language on TV or see a British play at the theater. All in all I managed quite well working as a nurse in the UK and I had a wonderful experience and made a lot of friends.
This year I am embarking on a new adventure and will be working in the USA. I look forward to the differences and the similarities that I will encounter and am up for a new and exciting experience to live in another country. I will let you know how I made out when I get back to Canada in 3 years. As for making beds, I know how to miter a corner and I know how to use fitted sheets so I should be OK!!
After all. the principles of nursing is the same no matter where you work.
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Ellen Nicholson | 31-Jan-2010 5:24 pm
I nursed in Germany for a while, they had fitted sheets and duvets - easy peasy!
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Anonymous | 31-Jan-2010 7:57 pm
Sara, If I were you I would still try to get fitted sheets as they are much more practical and comfortable for patients. If your administration say that all sheets need to be pressed then I would say that fitted sheets don't need to be pressed and would save a lot of time and money in not pressing them. Fitted sheets certainly aren't pressed where I work in Canada and they are soft and comfy for the patient. I think the problem is that England is too stuck in the past and is not open to change. Am I right or wrong?
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peepee A | 31-Jan-2010 9:14 pm
I really do feel you guys, i mean being in a school that still wears a hat and wears a dress and stockings what can i say. despite the fact that all our textbooks are american textbooks and a good number of our tutors are american trained, we are still stuck in the archaic form of nursing. nothing is computerised asides the clerk's notes, we still have to jot down during hand overs and hunt the pharmacy down for meds then mix them. infact it's hilarious but not only do we still make beds like the british, we still mix our hep flush ourselves with an 100ml NS bag and heparin, if the nurses choose to do so... it's ridiculous in this time and day but some nursing schools and teaching hospitals are still in the then days and al the evidence of technoloy we have is in our textbooks. Oh did i mention am a BSN student.... u can imagine how it was for my associate colleagues or the diploma nurses.... well the good thing is we're learning the hard way, bet it will help us to manage situations when technology fails....
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Anna Lincoln | 31-Jan-2010 9:25 pm
"I think the problem is that England is too stuck in the past and is not open to change. Am I right or wrong?"

100% right.
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Christopher Moulds | 31-Jan-2010 10:33 pm
Having nursed for 20 years in UK,
then 20 years in the US,I recently visited my 94 year old Mum(Mom) in a UK hospital.
It really was like stepping back in time,with the archaic unappealing nurses uniforms which must have been designed by Florence Nightingale herself...(OK the silly hats have finally been consigned to oblivion).
As for corners on sheets,I trained in RAMC and still make hospital (army) corners on top sheets AND blankets much to the amazement of my US counterparts.
I'm sure fitted sheets are better for our patients, and running round the bed lifting the mattress stretching them to the corners is healthy exercise for those of us with an unhealthy lifestyle.
The jury is still out on cost savings.
Nonetheless,despite my criticisms,
my Mum received exceptional and expensive medical.nursing and discharge planning care from a well organised treatment team ,which cannot be surpassed
in the best of US hospitals.
My thanks to Doncaster Royal Infirmary and the NHS.
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Anonymous | 1-Feb-2010 4:58 am
I am a UK trained nurse, currently working in Vancouver, Canada. I worked in the NHS for 17 years before coming to Canada, and am all too familiar with the outdated uniforms, caps, capes, hospital corners etc. But I have to say that working in scrubs (any cartoon character will do) just doesn't have the same professional appearance. Doctors, nurses, ward aides, care aides, porters - they all look the same!! There is no distinguishing whi is who. Also, the hospital where i work is so pleased we have finally gotten a vernacare bedpan macerator!!! they don't believe me when I tell them we had these 15 years ago in the NHS. We still have to hand wash plastic bedpans however and this is normal practice!!! Seems behind the times. And for those people not lucky enough to have an employer who pays for their health benefits, the cost of being ill/having a long term condition in Canada is astronomical. I know one thing for sure, in the UK we don't kow how lucky we are to have the NHS!!
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Anonymous | 1-Feb-2010 10:38 am
Aonymous at 4:58. I am not sure I understand your post. I thought that they had socialised medicine in Canada? Why do people there need employer provided health insurance? Is it so they can go to the USA for treatment because the socialised medicine is so horrific?
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Christy Griffin | 1-Feb-2010 10:48 am
I am an American, I worked as a nurse in the States, then left at age 27, to come work in the UK.

Of course, it was difficult to learn the drugs all over again, because brand names were not used in the UK. Making beds with pressed flat sheets was stupid. I got used to it, but found it a waste of time.

There are alot of things that the NHS could learn but, I did try helping change things when I arrived. But, like most of you have said, the UK nurses in their 40's & 50's, do not want to change. They like things as they are.

You need some American nurses to lead the way at the top - by an exchange programme. The NMC should start this, where we have a year of being re-trained by American staff, then the UK wouldn't be 10 years behind the USA.
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Julie Roberts | 1-Feb-2010 10:51 am
Hmmmm..... interesting, but true article.
I was trained and worked in one of the Caribbean islands, and I must say, that though we are considered 'developing countries', there is much that we do better at; and could more, if had the resources. Been working in the UK for 10years now- next Month to be exact(smile). My aim ten years ago, was to work and experience living in a different culture, and that I have! But I must say, Britain and the NHS has it's positives too(as well as it's negatives- OLD fashion's); patients are really priviliged to have FREE healthcare! One is lucky to have any surgery they like, and not pay for it(whether it's life threeatening or not)! Free medication....wow! At my home of origin, if you don't have the finances, then you either stay with your illness...possibly face death....or pray that God will keep you safe, and heal you.
Regarding nursing attire, I have never seen so many different kinds of uniforms and colours/colors! I am used to the white and in some hospitals in the Caribbean, nursing cap/hat is part of the dress code- I must say, I DO miss wearing my hat too! Yes, and even the different names of medications used: brand name versus trade names!
Looking at migrating to a different culture- hopefully soon-and I am sure it will be another adjustment,... though I was trained with somewhat of an American/British system.
Thanks for your article, it was an interesting read. Also, for the few responses I've read, they were interesting too.
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Anonymous | 1-Feb-2010 2:36 pm
I'm a student nurse about to qualify in the UK. I understand everybody's comments and do think we need to move with the times. Things are a little different (uniforms etc) here in Scotland than in England but the main fundamental problem is the same - money. The NHS will not pay for every sheet in the country to become fitted. Even though it could be suggested that costs would be lower due to not needing to press them they just won't do it. Luckily America has most people paying for healthcare.
In my area we are told that there is a severe shortage of nurses in general and yet I have friends who cannot find themselves a job. Why? Because health boards have admitted that they can't pay another nurse despite the shortage.
Always money and always will be :(
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Anonymous | 1-Feb-2010 10:38 pm
I recently qualified as a nurse in the UK. During my training I did an elective placement in Italy. Talk about backwards! I rarely saw anyone wash their hands and latex gloves weren't available in the wards. IVs were still made up in glass bottles and no-one signed for them or counter-checked the calculations - there were no namebands to check either. There was no equipment for safe manual handling such as hoists. Play therapy was not used in paediatrics so it was common to hear a child screaming down the corridor as they were receving venepuncture. It made me see the NHS in a whole new light..! On the plus side, the hospital had an effective recyling programme. In every ward there were bins for glass, paper and plastic - something I would like to see introduced in the UK as there is an incredible amount of waste produced in clinical settings from packaging etc.
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Anonymous | 2-Feb-2010 11:54 am
I'm not sure why she bothered to write that article apart from seing her name in print.
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Anonymous | 2-Feb-2010 3:32 pm
I am in my final year in the UK and am currently on a 7 month placement in Italy. I believe that each country has positive and negative sides to the profession. Although some things in Italy are done differently to the UK they are not all bad. Nurses often carry out tasks which can only be done by doctors in the UK, unless they have specifical advanced training, and they are way ahead of us on their theory as most of the subjects taught to students at uni are done by doctors. Also different departments and hospitals mean different budgeting...so in paeds we had to be careful of how much X or Y we were using at the end of the year, whereas in Cardiology High Dependency there are latex gloves, hoists do exist but are not used due to pure laziness, IV's are maily in "plastic" bags, drugs are countersigned and drug errors are a rarity as are HAI's!
However, I agree that a simple sliding sheet could be introduced onto the wards as the Italian health system would save on nurses having to take time off due to hernias!!!
This goes to show that no one country is perfect.....what would be good is to integrate the best from all countries to provide a better service to the patient and a better working environment for the nurse.
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Anonymous | 2-Feb-2010 11:48 pm
I am a British nurse who lived in Italy for 13 years but regularly returned to the UK to do bank work and study at uni. I also worked in a private hospital in my home town in Central Italy where I can honestly say that every day I performed tasks according to the hospital's policy that I would have been struck off the register for had I done these same tasks in a UK hospital. For example, mixing up drug additives but not label the syringes, never signing for administered medicines, write prescriptions out in pencil, never performed patient care as their needs were considered irrelevant, never feed in any way patients with dysphagia as nurses couldn't take responsibility, male nurses having sexual relations with patients, physically holding patients down to save on anaesthetist cost, patients refered to by their bed no.... the list is exhaustive, but unfortunately true. Nursing in Italy is doctor orientated not patient centred. Nurses comand little or no respect from the general public, it is not even considered a profession. On returning to the UK I find the NHS a different place yes, but as far as the great American way of life goes, let's face it, it's no bed of roses there either, they're just more vocal about how wonderful and forward thinking they are as opposed to British nurses who are modest despite it being British nurses from the Nightingale School of Nursing in London that took modern nursing to the wider world. Study the history of Nursing in any European country and you'll find amongst those dusty old archives the names of Florence Nightingales first students and St. Thomas's schooled nurses with her hospital corners and all!!
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Anonymous | 3-Feb-2010 3:54 am
(Writer of comment about 3 month elective in Italy above)

I'm really interested to hear the experiences of other nurses in Italy! I had the same impression of the writer above that many things I would have had to do as a nurse in Itay would have me struck off the register here - the potential for drug errors and HAIs was enormous and put me off working there altogether. However it is very interesting to hear from the other writer that it can vary depending on the department.
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Anonymous | 3-Feb-2010 7:24 am
British Nurses are intelligent, forward thinking and hardworking. It's not the nurses who are backward, it's the UK hospitals that are backward.
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Anonymous | 3-Feb-2010 1:51 pm
I have a very different viewpoint on this...I worked in the UK for 10 years (mainly in ITU) before coming to the US to work. My jaw hit the floor when I started working here at just how outdated everything was/is. I work in a 300 bed suburban hospital and not a large teaching hospital, but still. As a pp from Canada noted, we still hand wash bedpans and urinals. Our ventilators are huge, old machines, not the touch screen vents/monitors I used in the UK (6 years ago). We still have no pharmacy out of hours (we did in the UK) and frequently accept 2/3 ICU patients instead of 1:1 care (which I believe is still the norm in the UK) and no we do not have people who draw labs, place IVs or give nebs( which people oftenthink is the reason for having 2/3 patents), it is still done by the RN. There is a misconception here that all US hospitals are well funded with lots of staff and modern equipment but that is simply false. Our ICU beds do not weigh patients, we have a hand operated hoist, not an automatic one (all things we had in the UK). Step away from the medical hub of a large city (just a handful of miles away) and things are very different in a lot of cases. Again, it may be different speaking from an ICU standpoint as I cannot comment on the wards/floors, but I would absolutely rather be cared for in a UK ICU than the ones I have seen over here (where every sedated patient is tied to the bed with restraints, so the RN can care for her other 2 patients without fear of extubation).
Just a different side of the story.
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