Jolly Good
British nurses fare well with automatic pay raises, government-paid nursing school fees and more clinical authority

By Heather World
October 29, 2003

The first difference that Bethann Siviter, RN, noticed when she left the United States to pursue a nursing career in England was the uniforms.

"Being from the States, I associated blue uniforms with physical therapy," said the former LPN. "Here, nurses wear blue. The darker the blue, the higher the level of nurse. It was the weirdest thing."

So, Siviter donned her light blue uniform and requisite black shoes and started training as a nurse in the United Kingdom. Five years later, she is entering the profession with a degree she said she could not have afforded in the United States and a starting vacation allowance of five weeks a year.

Nurses may capture the public's imagination the same way in both countries-patients on both sides of the Atlantic look to their nurses for clear advice and detailed explanations-but socialized medicine in the United Kingdom means significant differences for the nurses themselves. Career advancement and pay structure may seem rigidly defined and less rewarding to individuals in the United Kingdom, but British nurses have strong job security, subsidized education and-depending on training-the right to perform minor surgeries.

Between two-thirds and three-quarters of Britain's estimated 450,000 active registered nurses work in the hospitals and clinics of the National Health System, the government-financed health care program available to every citizen of the United Kingdom.

State-sponsored medicine extends to nurse training in England, Scotland, Wales and Northern Ireland-the four countries that make up the United Kingdom.

Educational assistance

"Here, they don't get paid a lot of money, but they get supported by the government while they get their degree," Siviter said. The British government paid Siviter's course fees, her uniform costs, plus the equivalent of a $720 monthly stipend during her three-year education to get a diploma. Her training included classes plus a dozen six- to eight-week placements in clinical environments. As with all British nursing students, she studied nursing basics her first year, then chose to continue in one of four specialty areas: adult health, mental health, learning disabilities or children's health.

Siviter opted to continue for a fourth year, which will end in a specialized degree. She is sponsored by her employer, who has paid her a year's salary of about $30,000 while the government paid her tuition.

With her degree and certifications, Siviter will be a "community specialist district nurse," the equivalent of a visiting nurse in the United States. In the compartmentalized world of British medicine, she must have a special license to work in this field, but she also has more clinical authority than her American counterparts. She can write prescriptions related to care outside the hospital for blood glucose monitoring machines or for medicines to treat lice and constipation.

The downside of a state-directed health care system, Siviter said, is the rigidity with which jobs are defined. Nurses enter the profession at a given "grade," depending on their education and experience. Career advancement between grades is not automatic. Nurses must apply for a job at the next grade if they wish to move forward.

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."

A top-down system also means uniformity for nurses across the United Kingdom. For example, the 2002 salary for every registered nurse with no special license in the United Kingdom was the equivalent of $27,266, except for those working in London, who earn extra money for living in one of the world's most expensive cities.

In the United States, the 2001 average salary of a nurse in Jackson, Miss., was $40,360 and the average salary of a nurse in Los Angeles was $55,860.

Yankee influence

The British system may be moving toward an American model. Clark cites the phrase, "When America sneezes, Britain catches cold," she added, "and the incubation time is getting shorter."

Although private care is not comprehensive in the United Kingdom, it offers certain elective surgeries and most long-term care. At present, about 100,000 nurses work outside the NHS, most in nursing homes that are subsidized but not run by the state.

"Many thought they were moving into an area where they could provide better quality care," Clark said. And, in the beginning, things were better.

"They were never paid better, but the environment was better and they tended to have more autonomy," she said. But long-term care is subsidized at a cost lower than actual price. Consequently, working conditions for nurses have declined.

American Magnet hospitals also have caught the attention of British policy-makers, said Sue Machell, MBA, RN, a registered midwife and registered health visitor. Like Yaseen, Machell visited the United States to observe American nursing practices as part of her job as a fellow in education and leadership development. Some NHS entities may be allowed to entice good nurses with extra incentives.

"In the United States, people probably wouldn't be too bothered about that," she said. "Here, people would be incensed. Socialized medicine is kind of stamped through us like a piece of rock."

Nevertheless, Machell has seen a lot of American ideas work in Britain. When she worked on the floor, colleagues consistently looked across the Atlantic for new ideas.

For her part, Siviter likes aspects of both the American and the British systems, although she said the changes in education, pay and responsibilities make the United Kingdom an exciting place to work right now.

"Nursing here is not the same as America, but it's good," she said. "I wouldn't be an RN today if it wasn't for British nursing."

Contact Heather World at H_world@yahoo.com