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Nursing Work and Life
A comparison of the education and work experiences of immigrant and the United States of America-trained nurses O. Mazurenko1 PhD, MD, MS, G. Gupte2 PhD, MBA & G. Shan3 PhD 1 Assistant Professor, Health Care Administration and Policy, 3 Assistant Professor, Environmental and Occupational Health, School of Community Health Sciences, University of Nevada, Las Vegas, NV, 2 Assistant Professor, Health Policy and Management, School of Public Health, Boston University, Boston, MA, USA
MAZURENKO O., GUPTE G. & SHAN G. (2014) A comparison of the education and work experiences of immigrant and the United States of America-trained nurses. International Nursing Review 61, 472–478 Aim: This study examined the education and work experience of immigrant and American-trained registered nurses from 1988 to 2008. Background: The USA increasingly relies on immigrant nurses to fill a significant nursing shortage. These nurses receive their training overseas, but can obtain licenses to practice in different countries. Introduction: Although immigrant nurses have been in the USA workforce for several decades, little is known about how their education and work experience compares with USA-trained nurses. Yet much is presumed by policy makers and administrators who perpetuate the stereotype that immigrant nurses are not as qualified. Methods: We analysed the National Sample Survey of Registered Nurses datasets from 1988 to 2008 using the Cochran–Armitage trend tests. Results: Our findings showed similar work experience and upward trends in education among both groups of nurses. However, American-trained nurses were more likely to further advance their education, whereas immigrant nurses were more likely to have more work experience and practice in a wider range of healthcare settings. Discussion: Although we discovered differences between nurses trained in the USA and abroad, we theorize that these differences even out, as education and work experience each have their own distinct caregiving advantages. Conclusion: Immigrant nurses are not less qualified than their American-trained counterparts. However, healthcare providers should encourage them to further pursue their education and certifications. Implications for nursing and health policy: Even though immigrant nurses’ education and work experience are comparable with their American counterparts, workforce development policies may be particularly beneficial for this group.
Correspondence address: Dr Olena Mazurenko, Health Care Administration and Policy, School of Community Health Sciences, University of Nevada, 4505 S Maryland Parkway, Box 453023, Las Vegas, NV 89123, USA; Tel: 702-895-30-91; Fax: 702-895-5184; E-mail: [email protected].
Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest Olena Mazurenko: None. Gouri Gupte: None. Guogen Shan: None.
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Immigrant and US-trained nurses
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Keywords: Education, Immigrant Nurse, Trend, United States of America, Workforce
Introduction Several developed countries rely on immigrant nurses (INs) to fill nursing shortages (Brush et al. 2004). These nurses receive their training overseas, but can obtain licenses to practice in different countries. INs comprise approximately 12–15% of the nursing workforce in the USA (Galarneau 2003; National Council of State Boards of Nursing 2012). Apart from filling the nursing shortage, INs contribute to a reduction in turnover (Aiken et al. 2004; Bureau of Labor Statistics 2010; Polsky et al. 2007) and are willing to work in a wider variety of settings, including long-term care facilities (Aiken et al. 2004; Buchan et al. 2003; Bureau of Labor Statistics 2010; Polsky et al. 2007; Redfoot & Houser 2005). The Institute of Medicine’s (2011) ‘Future of Nursing: Leading Change, Advancing Health’ report highlights the importance of nursing education, as growing evidence associates it with better quality care. Although INs have been in the USA workforce for several decades, little is known about how their education and work experience compares with USAtrained nurses. The limited evidence suggests that INs may have less education than their USA counterparts (Aiken et al. 2004; Polsky et al. 2007). This is important as concerns have been raised regarding the quality of care provided by INs due to potentially different education and experience (Brush et al. 2004; Polsky et al. 2007; Xue et al. 2012). To our knowledge, little research has been conducted globally to support or oppose this assumption. This study was designed to compare INs and USA registered nurses (USA RNs) according to trends in demographics, education and work experience. The results can assist healthcare managers understand the education and work experience of their workforce and appropriately align recruitment and retention strategies. Policy makers may also consider information from this paper in the development of transitional programmes to better integrate INs in the workforce. Aim
To compare the education and work experience of INs and USA RNs from 1988 to 2008.
Methods Data source and study population
The National Sample Survey of Registered Nurses (NSSRN) datasets collected by Department of Health and Human Ser-
© 2014 International Council of Nurses
vices from 1988 to 2008 were used to compare the trends in education and work experience between IN and USA RNs. The NSSRN is based on a randomly selected sample of individual RNs from each state’s listing of licensed registered nurses. The data were collected through mailed paper surveys, Internet surveys and direct interviews. Our institutional review board approved this study. Dependent variable
The country where training was received was used as a dependent variable. Considering that all INs complete a similar rigorous certification process to be licensed in the USA, we assumed that all countries had comparable training programmes. In this study, an IN was described as a nurse whose initial RN education programme was located in a foreign country, and a USA RN as a nurse who graduated from a nursing school in the USA or its territories. Independent variables
The independent variables included education and work experience. Specifically, education was represented by the following variables: highest level of education, presence of additional qualifications, current enrolment in formal education programme and type of enrolled programme. Work experience was operationalized through the following variables: average number of years of nursing experience, employment setting, employment type, dominant function and principal RN position. Several control variables were included in our model: age, marital status and number of children in the household, gender and race/ethnicity. Age was operationalized as a categorical variable with four categories representing different generational categories. Marital status was measured by a categorical variable including marriage status and presence of children in the household. Race/ethnicity and gender were operationalized through categorical variables indicating an RN’s racial/ethnic background (e.g. white, non-Hispanic or other) and gender (Xu & Kwak 2007). Data analysis
A series of cross-sectional data was used to examine the education and work experience of immigrant and USA-trained registered nurses. Statistical analyses for trend tests for each category were performed for the years 1988–2008 using the Cochran–
© 2014 International Council of Nurses
3 754 (11.8%) 1 144 (73.9%) 28 050 (88.2%) 404 (26.1%) 2 751 (8.7%) 600 (61.4%) 28 838 (91.3%) 376 (38.5%) 3 800 (11.4%) 876 (67.8%) 29 389 (88.5%) 415 (32.1%) 1 870 (6.5%) 567 (57.6%) 26 703 (93.4%) 417 (42.3%) 1 722 (5.4%) 463 (51%) 30 158 (94.6%) 442 (48.8%)
IN, immigrant nurses; RN, registered nurses; USN, United States nurses.
1 868 (6%) 481 (57.2%)
878 (96.2%) 30 856 (96.4%) 34 (3.7%) 1 141 (3.5%)
29 290 (94%) 359 (42.7%)
1 417 (91.5%) 29 587 (93%) 131 (8.4%) 2 217 (6.9%) 986 (92.2%) 31 576 (94%) 83 (7.7%) 2 008 (5.9%) 1 219 (93.7%) 31 494 (94.2%) 81 (7.2%) 1 926 (5.7%) 928 (92.9%) 27 227 (94.7%) 70 (7.0%) 1 504 (5.2%) 799 (94.4%) 29 989 (95.7%)
998 (3.3%) 31 329 (97%) 846 (2.6%) 32 000 (97%)
47 (5.5%) 1 322 (4.2%)
1 548 (4.6%) 33 589 (96.9%) 1 070 (3.1%) 33 420 (96.2%) 1 300 (3.7%)
IN IN IN IN
USN
1992 1988
Years Characteristics
Table 1 Descriptive statistics of the IN and US RNs
USN
1996
Education
Our findings showed upward trends in education among both groups of nurses (see Fig. 1). However, American-trained nurses were more likely to obtain baccalaureate and master’s degrees, and INs and USA RNs differed in terms of additional qualifications. Specifically, the percentage of USA RNs who became certified nurse practitioners (the certified nurse practitioner qualification requires at least a master’s degree or a higher qualification in nursing and allows someone to practice under the supervision or consultation of the physician) steadily increased from 28% in 1992 to 54% in 2008, while the percentage of INs who received this qualification varied from 15.6% in 1992 to 60.7% in 2004 and 28.8% in 2008. Additionally, we observed an increase in USA RNs reporting current enrolment in formal education programme, from 17% in 1988 to 27% in 2008. The number of INs who reported pursuing additional degrees was low in 1988, but fluctuated in later years, from 17% in 1996 to 24% in 2004 and 17% in 2008. It was also observed that the majority of RNs enrolled in formal training were pursuing nursing (81% of USA RNs and 85% of INs) or a nonnursing field that enhanced their nursing career (11% of USA RNs and 9% of INs). Our findings also revealed that fewer RNs pursued clinical nurse specialty certification (the clinical nurse specialist is an advanced practice RN with graduate preparation
IN USN
2000
USN
2004
USN
The study sample consisted of 6674 and 190,885 INs and US RNs respectively. INs represent a growing percentage of the USA nursing workforce, increasing from 2.7 to 4.7% from 1988 to 2008. Changes in demographic characteristics of INs and their USA counterparts were also calculated (see Table 1). Briefly, over 20 years, the proportion of female RNs decreased, whereas male RNs increased between both groups. Additionally, a significantly lower proportion of RNs younger than age 35 have worked in nursing, for both groups. A growth in the number of nurses age 55 and older was observed for both INs and USA RNs. Our racial findings indicated a decline in white RNs and an increase in other ethnicity RNs practicing in the USA among both study groups. Finally, for both study groups, more nurses were married with no children, while a continuous decline was observed in RNs who were married with children.
28 743 (96%)
Demographic characteristics
912 (2.7%)
Results
Number Gender Male Female Race White Other
2008
USN
Armitage trend test. This method tests if a series of proportions vary linearly with an ordinal or continuous score variable. This analysis was performed using SAS statistical analysis software version 9.3. A nominal significance level of 0.05 was used (SAS Institute Inc., Cary, NC, USA).
31 804 (95%)
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IN
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Immigrant and US-trained nurses
475
60
0.15
56.1 50
0.12
0.12
49.4
0.12
43.4 40.2
0.09
34.5 30
30.1 28.3
30.5
31.8
33.0
34.7
Percentage
Percentage
40
35.8
20
0.09 0.08
0.07
0.07 0.08
0.06
0.08
0.07
0.07
0.07
US nurses completed bachelors
US nurses in nursing homes
10
0.03
INs completed bachelors 0 1984
0.07
1988
1992
1996
2000
2004
2008
INs in nursing homes 0 1984
2012
Year
1988
1992
1996
2000
2004
2008
2012
Year
18 90 79.07
14.5
15
78.39
75
13.5
71.30
74.06
70.73
76.07 67.66
Percentage
Percentage
12
10.6 9.7 7.9
9
8.8
6.2
5.2 3
US nurses completed masters INs completed masters 1996
2000
2004
2008
2012
Year
Fig. 1 Educational qualifications of immigrant nurses (INs) and US nurses, selected years 1988–2008.
and with clinical expertise in a specialized nursing practice) in both groups, decreasing from 52.6% in 1992 to 24.8% in 2008 among USA RNs and from 21 to 9% among INs. Work experience and employment setting
Since graduation from initial nursing education, INs ranged in average years of nursing experience from a low of 20 years in 1988 to a high of 22.5 years in 2008. For USA RNs, the range was from 16 years in 1988 to 20 in 2008. Across all survey years, USA RNs had on average 3 years less experience than INs and the difference was statistically significant. Our findings have shown that the percentage of USA RNs and INs working in hospitals varied considerably over 20 years. Specifically, both groups have experienced a decrease in number of nurses working in this setting from 1992 to 1996 (INs: from 67 to 61%; USA RNs: from 78 to 71%) with a subsequent increase in 2004 (INs: from 60 to 67%; USA RNs: from 70 to
© 2014 International Council of Nurses
60.40
US nurses in hospitals
5.5
1992
61.75 45
INs in hospitals
15
6.5
1988
60.23
67.82
30
9.2
7.3
6
0 1984
70.46
60
0 1984
1988
1992
1996
2000
2004
2008
2012
Year
Fig. 2 Trends in workplace settings of immigrant nurses (INs) and US RNs, selected years 1988–2008.
76%). Trend analysis revealed a continuous decrease in the proportion of INs working in a nursing home setting since 1996. Finally, we observed a downward trend in the proportion of RNs working in primary care-type setting (ambulatory care, public and community health settings) in both groups. The data also indicated that the proportion of full-time nurses working increased in both groups. Finally, we observed decreasing trends in the proportion of USA RNs and INs who had dominant position in administration, research or teaching (Fig. 2).
Discussion Given the increasing use of INs in developed countries, and the USA in particular, and the limited evidence regarding INs profiles, it is important to know more about IN characteristics to inform nursing workforce policy (Buerhaus et al. 2003, 2007a; Polsky et al. 2007). The data showed variations in the levels of education between the two nursing groups, but work experience was similar, indicating that INs need more support and incentives to further their education.
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Our study revealed an upward trend in bachelor and master’s level degrees among both INs and USA RNs, indicating that INs have kept pace with the increase in education among USA nurses (Institute of Medicine 2011). This information is encouraging due to growing evidence that a better-educated nursing workforce is associated with better care quality, indicated by lower patient mortality and medical error rates (Aiken et al. 2003; Kutney-Lee & Aiken 2008; Kutney-Lee et al. 2013). Additionally, these data support the Institute of Medicine’s (2011) goal of an 80% college-graduated nursing workforce by 2020. However, one educational difference observed between USA RNs and INs was an increasing number of USA RNs reporting current enrolment in formal educational programmes to enhance their career in nursing, while the number of INs fluctuated over time with enrolment decreasing in recent years. For example, we observed an increase in the percentage of USA RNs who became certified nurse practitioners, while the percentage of INs varied. This difference has several possible explanations. First, lower wages for INs in their early career (Buchan et al. 2003; Schumacher 2011) may be responsible for the reluctance of these nurses to spend money and time on further education. Second, the challenge of working and living in a new country and environment, language difficulties, lack of family support (Sochan & Singh 2007) and stigma associated with being an IN (Wheeler et al. 2013) may hinder INs’ desires to add additional qualifications to their skill sets (Edward 2000). Third, having moved from countries with very few resources and much lower wages, INs may be satisfied with their current working conditions (Aiken et al. 2004; Buchan et al. 2003; Kingma 2007; Xaba & Phillips 2001). Finally, it could be argued that INs are not able to allocate additional funding for additional degrees due to the need to support families abroad (Wheeler et al. 2013). Additionally, employer support for the pursuit of additional qualifications may play an important role (Aiken et al. 2004; Buchan et al. 2003). On the other hand, USA RNs may be more willing to pursue additional education due to greater opportunities to become administrators (Buerhaus et al. 2007b). Given the importance of nursing education in care quality, more research is needed to understand why INs practicing in the USA do not pursue additional education once they have satisfied the minimum required level. Additionally, it is worth investigating how other countries successfully encourage their nursing workforce to advance their education. For instance, UK has been working on the advancement of INs in order not only to actively encourage more recruitment, but also to improve growth and retention (Kawi and Xu 2009). Another important finding was that both groups of nurses had many years of nursing experience, with INs reporting at
© 2014 International Council of Nurses
least 3 more years’ experience than their USA counterparts. Previous research has shown that more experienced nurses provide better quality of care (Aiken et al. 2003; Blegen et al. 2001). Thus, INs’ additional experiences may be more beneficial to patient care. Furthermore, the data showed several shifts in the employment of INs and USA RNs in different healthcare settings from 1988 to 2008. Both groups saw fewer nurses working in the hospitals from 1992 to 1996, with a subsequent increase in 2004. On the other hand, the proportion of RNs working in a primary care setting decreased in both groups since 1996. These findings explain how market demand swings the recruitment of INs in varying nursing services and settings (Buerhaus et al. 2007a; Polsky et al. 2007; Xu & Kwak 2007). Consistent with existing literature (Beecroft et al. 2008; Branine 2003; Strachota et al. 2003; Tzeng 2002), our findings indicate that family commitment (e.g. caring for children) adversely affects the pursuit of a nursing career in both groups, as nurses with children decreased over 20 years. Additionally, we observed an increase in full-time employees. These findings support research reporting that healthcare institutions prefer full-time employment contracts and that inflexible and long (12 h) working shifts are one of the major reasons for nursing turnover (Cortelyou-Ward 2007; Cortelyou-Ward et al. 2010). Given the current nursing shortage, healthcare managers might want to consider adopting more flexible working schedules and part-time employment contracts that could attract parenting nurses back into workforce (Andrews et al. 2005; Cortelyou-Ward et al. 2010; Pearson et al. 2006). Finally, the data revealed an increasing number of older nurses in the workforce among both groups. This can be attributed to the economic crisis and increasing financial uncertainty in the USA (Unruh & Fottler 2005). This result also complements studies attributing most of the growth in nursing workforces to older nurses and INs (Auerbach et al. 2007, 2011; Buerhaus et al. 2007a). Scholars are concerned that once the economy stabilizes, these ageing nurses will leave the field, further contributing to the existing nursing shortage and adding pressure to the system (Buerhaus et al. 2009). Therefore, healthcare managers should consider recruiting more newly graduated nurses, who will be able to later replace ageing staff. Our study was also consistent with existing literature in observing an increase in the proportion of male RNs and decrease in female RNs, a decline in white RNs and an increase in other ethnicity RNs, among both study groups (Xu & Kwak 2007). These findings can be due to the increasing diversity of the American population and an economic situation that forces males to enter new profitable professions, such as nursing (Evans 1997).
Immigrant and US-trained nurses
Implications for nursing and health policy Adapting to the requirements of the Patient Protection and Affordable Care Act, similar to the concept of universal care in other countries, is going to intensify the nursing shortage and place additional pressure on the workforce. It is therefore important that USA policy makers consider this as an opportunity to provide much-needed resources and support to the nursing workforce. Without exception, continued education of INs and USA RNs is critical to improving healthcare quality. A special focus on promoting enhanced career options for INs needs to be considered. Additionally, the retention of nurses in organizations such as primary care and nursing homes requires USA policy makers to design incentive-based programmes or promotion strategies. Australia and Canada with universal healthcare systems have been considering easier citizenships for the INs. Finally, it is important to allocate resources to the development of state-level policies, similar to California’s, focusing on better and more flexible work schedules, child support programmes and ease of workforce entry post maternity leave. Nurses working towards immigrating to the USA should be cognizant of these requirements.
Limitations Considering the usage of secondary datasets, our study has two major limitations. First, the NSSRN undercounts INs by sampling the same number of nurses in each state, despite the fact that INs are mostly located in larger states. This can explain the lower number of INs observed in this study as compared with others (Schumacher 2011; Staiger et al. 2012). Despite these shortfalls in sampling procedure, NSSRN is the best-known dataset to study population of INs practicing in the USA (Xue et al. 2012). Second, the NSSRN datasets are based on selfreported data. Thus, our results may be biased by ‘memorability’ and ‘desirability’. However, our results closely corresponded with previous research on this topic (Polsky et al. 2007).
Conclusions Our findings indicate that INs who practice in the USA have adequate education and work experience to ensure their capacity to fill vacant nursing positions in a variety of healthcare settings. Therefore, the USA policy of recruiting INs to fill its nursing shortage is a safe strategy. However, we also suggest future workforce policies and incentive programmes encouraging INs to enrol in career-advancing educational programmes.
Author contributions OM was involved in the study conception and design and drafting of the manuscript. Additionally, the author provided critical
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revisions for important intellectual content and overall supervision of the project. GG was involved in the study conception and design and drafting of the manuscript. Additionally, the author provided critical revisions for important intellectual content. GS provided statistical expertise and performed the data analysis.
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Redfoot, D. & Houser, A. (2005) We Shall Travel on: Quality of Care, Economic Development, and the International Migration of Long-Term Care Workers, AARP Public Policy Institute, Washington, DC. Schumacher, E. (2011) Foreign born nurses in the U.S. labor market. Health Economics, 20, 362–378. Sochan, A. & Singh, M.D. (2007) Acculturation and socialization: voices of internationally educated nurses in Ontario. International Nursing Review, 54 (2), 130–136. Staiger, D., Auerbach, D. & Buerhaus, P. (2012) Registered nurse labor supply and the recession – are we in a bubble? New England Journal of Medicine, 366, 1463–1465. Strachota, E., et al. (2003) Reasons registered nurses leave or change employment status. Journal of Nursing Administration, 33, 111–117. Tzeng, H. (2002) The influence of nurses’ working motivation and job satisfaction on intention to quit: an empirical investigation in Taiwan. International Journal of Nursing Studies, 39, 867–878. Unruh, L. & Fottler, M. (2005) Projections and trends in RN supply: what do they tell us about the nursing shortage? Policy, Politics, & Nursing Practice, 6, 171–182. Wheeler, R., Foster, J. & Hepburn, K. (2013) The experiences of internationally educated nurses in the southeastern United States of America. International Nursing Review, 60, 397–404. Xaba, J. & Phillips, G. (2001) Understanding Nurse Emigration: Final Report. Trade Union Research Project, Pretoria. Xu, Y. & Kwak, C. (2007) Comparative trend analysis of characteristics of internationally educated nurses and U.S. educated nurses in the United States. International Nursing Review, 54, 78–84. Xue, Y., Smith, J., Freund, D. & Aiken, L. (2012) Supplemental nurses are just as educated, slightly less experienced, and more diverse compared to permanent nurses. Health Affairs, 31, 2510–2517.
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Nursing Work and Life
A comparison of the education and work experiences of immigrant and the United States of America-trained nurses O. Mazurenko1 PhD, MD, MS, G. Gupte2 PhD, MBA & G. Shan3 PhD 1 Assistant Professor, Health Care Administration and Policy, 3 Assistant Professor, Environmental and Occupational Health, School of Community Health Sciences, University of Nevada, Las Vegas, NV, 2 Assistant Professor, Health Policy and Management, School of Public Health, Boston University, Boston, MA, USA
MAZURENKO O., GUPTE G. & SHAN G. (2014) A comparison of the education and work experiences of immigrant and the United States of America-trained nurses. International Nursing Review 61, 472–478 Aim: This study examined the education and work experience of immigrant and American-trained registered nurses from 1988 to 2008. Background: The USA increasingly relies on immigrant nurses to fill a significant nursing shortage. These nurses receive their training overseas, but can obtain licenses to practice in different countries. Introduction: Although immigrant nurses have been in the USA workforce for several decades, little is known about how their education and work experience compares with USA-trained nurses. Yet much is presumed by policy makers and administrators who perpetuate the stereotype that immigrant nurses are not as qualified. Methods: We analysed the National Sample Survey of Registered Nurses datasets from 1988 to 2008 using the Cochran–Armitage trend tests. Results: Our findings showed similar work experience and upward trends in education among both groups of nurses. However, American-trained nurses were more likely to further advance their education, whereas immigrant nurses were more likely to have more work experience and practice in a wider range of healthcare settings. Discussion: Although we discovered differences between nurses trained in the USA and abroad, we theorize that these differences even out, as education and work experience each have their own distinct caregiving advantages. Conclusion: Immigrant nurses are not less qualified than their American-trained counterparts. However, healthcare providers should encourage them to further pursue their education and certifications. Implications for nursing and health policy: Even though immigrant nurses’ education and work experience are comparable with their American counterparts, workforce development policies may be particularly beneficial for this group.
Correspondence address: Dr Olena Mazurenko, Health Care Administration and Policy, School of Community Health Sciences, University of Nevada, 4505 S Maryland Parkway, Box 453023, Las Vegas, NV 89123, USA; Tel: 702-895-30-91; Fax: 702-895-5184; E-mail: [email protected].
Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest Olena Mazurenko: None. Gouri Gupte: None. Guogen Shan: None.
© 2014 International Council of Nurses
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Keywords: Education, Immigrant Nurse, Trend, United States of America, Workforce
Introduction Several developed countries rely on immigrant nurses (INs) to fill nursing shortages (Brush et al. 2004). These nurses receive their training overseas, but can obtain licenses to practice in different countries. INs comprise approximately 12–15% of the nursing workforce in the USA (Galarneau 2003; National Council of State Boards of Nursing 2012). Apart from filling the nursing shortage, INs contribute to a reduction in turnover (Aiken et al. 2004; Bureau of Labor Statistics 2010; Polsky et al. 2007) and are willing to work in a wider variety of settings, including long-term care facilities (Aiken et al. 2004; Buchan et al. 2003; Bureau of Labor Statistics 2010; Polsky et al. 2007; Redfoot & Houser 2005). The Institute of Medicine’s (2011) ‘Future of Nursing: Leading Change, Advancing Health’ report highlights the importance of nursing education, as growing evidence associates it with better quality care. Although INs have been in the USA workforce for several decades, little is known about how their education and work experience compares with USAtrained nurses. The limited evidence suggests that INs may have less education than their USA counterparts (Aiken et al. 2004; Polsky et al. 2007). This is important as concerns have been raised regarding the quality of care provided by INs due to potentially different education and experience (Brush et al. 2004; Polsky et al. 2007; Xue et al. 2012). To our knowledge, little research has been conducted globally to support or oppose this assumption. This study was designed to compare INs and USA registered nurses (USA RNs) according to trends in demographics, education and work experience. The results can assist healthcare managers understand the education and work experience of their workforce and appropriately align recruitment and retention strategies. Policy makers may also consider information from this paper in the development of transitional programmes to better integrate INs in the workforce. Aim
To compare the education and work experience of INs and USA RNs from 1988 to 2008.
Methods Data source and study population
The National Sample Survey of Registered Nurses (NSSRN) datasets collected by Department of Health and Human Ser-
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vices from 1988 to 2008 were used to compare the trends in education and work experience between IN and USA RNs. The NSSRN is based on a randomly selected sample of individual RNs from each state’s listing of licensed registered nurses. The data were collected through mailed paper surveys, Internet surveys and direct interviews. Our institutional review board approved this study. Dependent variable
The country where training was received was used as a dependent variable. Considering that all INs complete a similar rigorous certification process to be licensed in the USA, we assumed that all countries had comparable training programmes. In this study, an IN was described as a nurse whose initial RN education programme was located in a foreign country, and a USA RN as a nurse who graduated from a nursing school in the USA or its territories. Independent variables
The independent variables included education and work experience. Specifically, education was represented by the following variables: highest level of education, presence of additional qualifications, current enrolment in formal education programme and type of enrolled programme. Work experience was operationalized through the following variables: average number of years of nursing experience, employment setting, employment type, dominant function and principal RN position. Several control variables were included in our model: age, marital status and number of children in the household, gender and race/ethnicity. Age was operationalized as a categorical variable with four categories representing different generational categories. Marital status was measured by a categorical variable including marriage status and presence of children in the household. Race/ethnicity and gender were operationalized through categorical variables indicating an RN’s racial/ethnic background (e.g. white, non-Hispanic or other) and gender (Xu & Kwak 2007). Data analysis
A series of cross-sectional data was used to examine the education and work experience of immigrant and USA-trained registered nurses. Statistical analyses for trend tests for each category were performed for the years 1988–2008 using the Cochran–
© 2014 International Council of Nurses
3 754 (11.8%) 1 144 (73.9%) 28 050 (88.2%) 404 (26.1%) 2 751 (8.7%) 600 (61.4%) 28 838 (91.3%) 376 (38.5%) 3 800 (11.4%) 876 (67.8%) 29 389 (88.5%) 415 (32.1%) 1 870 (6.5%) 567 (57.6%) 26 703 (93.4%) 417 (42.3%) 1 722 (5.4%) 463 (51%) 30 158 (94.6%) 442 (48.8%)
IN, immigrant nurses; RN, registered nurses; USN, United States nurses.
1 868 (6%) 481 (57.2%)
878 (96.2%) 30 856 (96.4%) 34 (3.7%) 1 141 (3.5%)
29 290 (94%) 359 (42.7%)
1 417 (91.5%) 29 587 (93%) 131 (8.4%) 2 217 (6.9%) 986 (92.2%) 31 576 (94%) 83 (7.7%) 2 008 (5.9%) 1 219 (93.7%) 31 494 (94.2%) 81 (7.2%) 1 926 (5.7%) 928 (92.9%) 27 227 (94.7%) 70 (7.0%) 1 504 (5.2%) 799 (94.4%) 29 989 (95.7%)
998 (3.3%) 31 329 (97%) 846 (2.6%) 32 000 (97%)
47 (5.5%) 1 322 (4.2%)
1 548 (4.6%) 33 589 (96.9%) 1 070 (3.1%) 33 420 (96.2%) 1 300 (3.7%)
IN IN IN IN
USN
1992 1988
Years Characteristics
Table 1 Descriptive statistics of the IN and US RNs
USN
1996
Education
Our findings showed upward trends in education among both groups of nurses (see Fig. 1). However, American-trained nurses were more likely to obtain baccalaureate and master’s degrees, and INs and USA RNs differed in terms of additional qualifications. Specifically, the percentage of USA RNs who became certified nurse practitioners (the certified nurse practitioner qualification requires at least a master’s degree or a higher qualification in nursing and allows someone to practice under the supervision or consultation of the physician) steadily increased from 28% in 1992 to 54% in 2008, while the percentage of INs who received this qualification varied from 15.6% in 1992 to 60.7% in 2004 and 28.8% in 2008. Additionally, we observed an increase in USA RNs reporting current enrolment in formal education programme, from 17% in 1988 to 27% in 2008. The number of INs who reported pursuing additional degrees was low in 1988, but fluctuated in later years, from 17% in 1996 to 24% in 2004 and 17% in 2008. It was also observed that the majority of RNs enrolled in formal training were pursuing nursing (81% of USA RNs and 85% of INs) or a nonnursing field that enhanced their nursing career (11% of USA RNs and 9% of INs). Our findings also revealed that fewer RNs pursued clinical nurse specialty certification (the clinical nurse specialist is an advanced practice RN with graduate preparation
IN USN
2000
USN
2004
USN
The study sample consisted of 6674 and 190,885 INs and US RNs respectively. INs represent a growing percentage of the USA nursing workforce, increasing from 2.7 to 4.7% from 1988 to 2008. Changes in demographic characteristics of INs and their USA counterparts were also calculated (see Table 1). Briefly, over 20 years, the proportion of female RNs decreased, whereas male RNs increased between both groups. Additionally, a significantly lower proportion of RNs younger than age 35 have worked in nursing, for both groups. A growth in the number of nurses age 55 and older was observed for both INs and USA RNs. Our racial findings indicated a decline in white RNs and an increase in other ethnicity RNs practicing in the USA among both study groups. Finally, for both study groups, more nurses were married with no children, while a continuous decline was observed in RNs who were married with children.
28 743 (96%)
Demographic characteristics
912 (2.7%)
Results
Number Gender Male Female Race White Other
2008
USN
Armitage trend test. This method tests if a series of proportions vary linearly with an ordinal or continuous score variable. This analysis was performed using SAS statistical analysis software version 9.3. A nominal significance level of 0.05 was used (SAS Institute Inc., Cary, NC, USA).
31 804 (95%)
O. Mazurenko et al.
IN
474
Immigrant and US-trained nurses
475
60
0.15
56.1 50
0.12
0.12
49.4
0.12
43.4 40.2
0.09
34.5 30
30.1 28.3
30.5
31.8
33.0
34.7
Percentage
Percentage
40
35.8
20
0.09 0.08
0.07
0.07 0.08
0.06
0.08
0.07
0.07
0.07
US nurses completed bachelors
US nurses in nursing homes
10
0.03
INs completed bachelors 0 1984
0.07
1988
1992
1996
2000
2004
2008
INs in nursing homes 0 1984
2012
Year
1988
1992
1996
2000
2004
2008
2012
Year
18 90 79.07
14.5
15
78.39
75
13.5
71.30
74.06
70.73
76.07 67.66
Percentage
Percentage
12
10.6 9.7 7.9
9
8.8
6.2
5.2 3
US nurses completed masters INs completed masters 1996
2000
2004
2008
2012
Year
Fig. 1 Educational qualifications of immigrant nurses (INs) and US nurses, selected years 1988–2008.
and with clinical expertise in a specialized nursing practice) in both groups, decreasing from 52.6% in 1992 to 24.8% in 2008 among USA RNs and from 21 to 9% among INs. Work experience and employment setting
Since graduation from initial nursing education, INs ranged in average years of nursing experience from a low of 20 years in 1988 to a high of 22.5 years in 2008. For USA RNs, the range was from 16 years in 1988 to 20 in 2008. Across all survey years, USA RNs had on average 3 years less experience than INs and the difference was statistically significant. Our findings have shown that the percentage of USA RNs and INs working in hospitals varied considerably over 20 years. Specifically, both groups have experienced a decrease in number of nurses working in this setting from 1992 to 1996 (INs: from 67 to 61%; USA RNs: from 78 to 71%) with a subsequent increase in 2004 (INs: from 60 to 67%; USA RNs: from 70 to
© 2014 International Council of Nurses
60.40
US nurses in hospitals
5.5
1992
61.75 45
INs in hospitals
15
6.5
1988
60.23
67.82
30
9.2
7.3
6
0 1984
70.46
60
0 1984
1988
1992
1996
2000
2004
2008
2012
Year
Fig. 2 Trends in workplace settings of immigrant nurses (INs) and US RNs, selected years 1988–2008.
76%). Trend analysis revealed a continuous decrease in the proportion of INs working in a nursing home setting since 1996. Finally, we observed a downward trend in the proportion of RNs working in primary care-type setting (ambulatory care, public and community health settings) in both groups. The data also indicated that the proportion of full-time nurses working increased in both groups. Finally, we observed decreasing trends in the proportion of USA RNs and INs who had dominant position in administration, research or teaching (Fig. 2).
Discussion Given the increasing use of INs in developed countries, and the USA in particular, and the limited evidence regarding INs profiles, it is important to know more about IN characteristics to inform nursing workforce policy (Buerhaus et al. 2003, 2007a; Polsky et al. 2007). The data showed variations in the levels of education between the two nursing groups, but work experience was similar, indicating that INs need more support and incentives to further their education.
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Our study revealed an upward trend in bachelor and master’s level degrees among both INs and USA RNs, indicating that INs have kept pace with the increase in education among USA nurses (Institute of Medicine 2011). This information is encouraging due to growing evidence that a better-educated nursing workforce is associated with better care quality, indicated by lower patient mortality and medical error rates (Aiken et al. 2003; Kutney-Lee & Aiken 2008; Kutney-Lee et al. 2013). Additionally, these data support the Institute of Medicine’s (2011) goal of an 80% college-graduated nursing workforce by 2020. However, one educational difference observed between USA RNs and INs was an increasing number of USA RNs reporting current enrolment in formal educational programmes to enhance their career in nursing, while the number of INs fluctuated over time with enrolment decreasing in recent years. For example, we observed an increase in the percentage of USA RNs who became certified nurse practitioners, while the percentage of INs varied. This difference has several possible explanations. First, lower wages for INs in their early career (Buchan et al. 2003; Schumacher 2011) may be responsible for the reluctance of these nurses to spend money and time on further education. Second, the challenge of working and living in a new country and environment, language difficulties, lack of family support (Sochan & Singh 2007) and stigma associated with being an IN (Wheeler et al. 2013) may hinder INs’ desires to add additional qualifications to their skill sets (Edward 2000). Third, having moved from countries with very few resources and much lower wages, INs may be satisfied with their current working conditions (Aiken et al. 2004; Buchan et al. 2003; Kingma 2007; Xaba & Phillips 2001). Finally, it could be argued that INs are not able to allocate additional funding for additional degrees due to the need to support families abroad (Wheeler et al. 2013). Additionally, employer support for the pursuit of additional qualifications may play an important role (Aiken et al. 2004; Buchan et al. 2003). On the other hand, USA RNs may be more willing to pursue additional education due to greater opportunities to become administrators (Buerhaus et al. 2007b). Given the importance of nursing education in care quality, more research is needed to understand why INs practicing in the USA do not pursue additional education once they have satisfied the minimum required level. Additionally, it is worth investigating how other countries successfully encourage their nursing workforce to advance their education. For instance, UK has been working on the advancement of INs in order not only to actively encourage more recruitment, but also to improve growth and retention (Kawi and Xu 2009). Another important finding was that both groups of nurses had many years of nursing experience, with INs reporting at
© 2014 International Council of Nurses
least 3 more years’ experience than their USA counterparts. Previous research has shown that more experienced nurses provide better quality of care (Aiken et al. 2003; Blegen et al. 2001). Thus, INs’ additional experiences may be more beneficial to patient care. Furthermore, the data showed several shifts in the employment of INs and USA RNs in different healthcare settings from 1988 to 2008. Both groups saw fewer nurses working in the hospitals from 1992 to 1996, with a subsequent increase in 2004. On the other hand, the proportion of RNs working in a primary care setting decreased in both groups since 1996. These findings explain how market demand swings the recruitment of INs in varying nursing services and settings (Buerhaus et al. 2007a; Polsky et al. 2007; Xu & Kwak 2007). Consistent with existing literature (Beecroft et al. 2008; Branine 2003; Strachota et al. 2003; Tzeng 2002), our findings indicate that family commitment (e.g. caring for children) adversely affects the pursuit of a nursing career in both groups, as nurses with children decreased over 20 years. Additionally, we observed an increase in full-time employees. These findings support research reporting that healthcare institutions prefer full-time employment contracts and that inflexible and long (12 h) working shifts are one of the major reasons for nursing turnover (Cortelyou-Ward 2007; Cortelyou-Ward et al. 2010). Given the current nursing shortage, healthcare managers might want to consider adopting more flexible working schedules and part-time employment contracts that could attract parenting nurses back into workforce (Andrews et al. 2005; Cortelyou-Ward et al. 2010; Pearson et al. 2006). Finally, the data revealed an increasing number of older nurses in the workforce among both groups. This can be attributed to the economic crisis and increasing financial uncertainty in the USA (Unruh & Fottler 2005). This result also complements studies attributing most of the growth in nursing workforces to older nurses and INs (Auerbach et al. 2007, 2011; Buerhaus et al. 2007a). Scholars are concerned that once the economy stabilizes, these ageing nurses will leave the field, further contributing to the existing nursing shortage and adding pressure to the system (Buerhaus et al. 2009). Therefore, healthcare managers should consider recruiting more newly graduated nurses, who will be able to later replace ageing staff. Our study was also consistent with existing literature in observing an increase in the proportion of male RNs and decrease in female RNs, a decline in white RNs and an increase in other ethnicity RNs, among both study groups (Xu & Kwak 2007). These findings can be due to the increasing diversity of the American population and an economic situation that forces males to enter new profitable professions, such as nursing (Evans 1997).
Immigrant and US-trained nurses
Implications for nursing and health policy Adapting to the requirements of the Patient Protection and Affordable Care Act, similar to the concept of universal care in other countries, is going to intensify the nursing shortage and place additional pressure on the workforce. It is therefore important that USA policy makers consider this as an opportunity to provide much-needed resources and support to the nursing workforce. Without exception, continued education of INs and USA RNs is critical to improving healthcare quality. A special focus on promoting enhanced career options for INs needs to be considered. Additionally, the retention of nurses in organizations such as primary care and nursing homes requires USA policy makers to design incentive-based programmes or promotion strategies. Australia and Canada with universal healthcare systems have been considering easier citizenships for the INs. Finally, it is important to allocate resources to the development of state-level policies, similar to California’s, focusing on better and more flexible work schedules, child support programmes and ease of workforce entry post maternity leave. Nurses working towards immigrating to the USA should be cognizant of these requirements.
Limitations Considering the usage of secondary datasets, our study has two major limitations. First, the NSSRN undercounts INs by sampling the same number of nurses in each state, despite the fact that INs are mostly located in larger states. This can explain the lower number of INs observed in this study as compared with others (Schumacher 2011; Staiger et al. 2012). Despite these shortfalls in sampling procedure, NSSRN is the best-known dataset to study population of INs practicing in the USA (Xue et al. 2012). Second, the NSSRN datasets are based on selfreported data. Thus, our results may be biased by ‘memorability’ and ‘desirability’. However, our results closely corresponded with previous research on this topic (Polsky et al. 2007).
Conclusions Our findings indicate that INs who practice in the USA have adequate education and work experience to ensure their capacity to fill vacant nursing positions in a variety of healthcare settings. Therefore, the USA policy of recruiting INs to fill its nursing shortage is a safe strategy. However, we also suggest future workforce policies and incentive programmes encouraging INs to enrol in career-advancing educational programmes.
Author contributions OM was involved in the study conception and design and drafting of the manuscript. Additionally, the author provided critical
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revisions for important intellectual content and overall supervision of the project. GG was involved in the study conception and design and drafting of the manuscript. Additionally, the author provided critical revisions for important intellectual content. GS provided statistical expertise and performed the data analysis.
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