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On the other hand, raises are automatic. Each grade has about four pay levels, and nurses advance through them year by year together, almost regardless of performance or demand for a particular specialty. Only an egregious mistake will prevent a nurse from moving up the pay scale within their grade.

Such a system changes the employer-employee relationship, said Talib Yaseen, MA, RN, chief nurse of North Cumbria Acute Hospitals NHS Trust.

Yaseen visited three major hospitals and a handful of health care facilities across the United States for three years, talking to staff and observing the American medical system.

"At one level, there's a greater sense of empowerment and accountability in the States," he said. "If you don't deliver, you're not going to be around."

U.K. nurses have more job security, but in poorly run facilities, they often lack that sense of accountability, he said.

Overall, Yaseen said, he believes the nurses in the United States expressed a greater sense of being an important part of what would make the organization successful.

"Nurses said to me, 'If we aren't successful, we can't deliver our mission,' " he said.

Strong voice

U.K. nurses do feel a strong sense of connection to the Royal College of Nursing, a combination union and professional organization, she said. Most nurses can name its chief executive and are aware of the dominant role the organization plays in U.K. nursing.

"I found it very exciting to have an accessible and active professional body that is U.K.-wide," she said.

Caroline Hyde-Price, MBA, RN, head of international affairs for the RCN, said its 360,000 members make it an influential voice for nurses. (Another estimated 250,000 nurses belong to the trade union Unison.) She named gains for nurses won by the organization during negotiations with the government to devise a new system for salary and career advancement. Even within the government, nurses have a strong voice, Hyde-Price added. The Department of Health has a chief nursing officer who can advise on health policies from the inside.

The RCN also must keep pace with directives issued from the European Union, which guides labor law for its 15 member nations.

Already, nurses in the United Kingdom perform Pap smears and minor surgeries like the removal of moles. They also deliver babies and suture patients. Most of these advanced responsibilities require special education and certification or "qualification," in British terms.

Nursing education has changed considerably in the United Kingdom in the past 20 years, said professor James Buchan, who specializes in nursing workforce policy research at Queen Margaret University College in Edinburgh, Scotland.

Once educated in hospital-sponsored programs, British nurses now attend colleges to earn their diplomas and, increasingly, their degrees. Some argue that the degree-based education has given the occupation a wider appeal, Buchan said. More men (one in 10 British nurses are men) and more individuals in their late 20s and early 30s are joining the field.

Yet integration into university education is not complete, said professor Dame June Clark, Ph.D, RN, recently retired from the University of Wales Swansea.

"The tradition of British nursing is very pragmatic and anti-intellectual," said the former president of the RCN. "Given for population differences, we don't have one-tenth of the master's-prepared or doctorally prepared nurses you do."

Nonetheless, the flow of new students has helped ease Britain's nursing shortage, but state-run health care has played a role in this arena, too. National initiatives, complete with funding and refresher training, entice nurses to return to the field. Additionally, England has a state-sponsored program to recruit foreign nurses.

"Because the health system in the U.K. is primarily NHS, it's top-down and policy-driven in a way the health care system in the U.S. can't be," Buchan said. "It's easier to point to national initiatives and interventions in the U.K. which are designed to address problems."