How to positively integrate
internationally
Universal issues
By Claudia DiSabatino Smith, PhD, RN, NE-BC, and Judy Ong Ho, MSN, RN, ACNS-BC, CPHQ
I
nt nternationally n educated nurses (IENs) comprise 5.6% of the (IE RN RN workforce in the United 1 States. St Nursing experts suggest that this number will conge tinue to rise; the United States tin draws the highest number of d aws dr IENs.2,3 For decades, administrators have used international recruiting as one strategy for
30
overcoming the U.S. nursing shortage. IEN transition, integration, and retention are a significant concern, due to the number and expense of recruitment and orientation.4 Administrators have used international nurse residency programs to facilitate IEN integration into U.S. nursing practice culture and institutional culture; however,
June 2014 • Nursing Management
little research has focused on the IENs’ perspectives on the international residency program in acculturating and integrating them into U.S. nursing practice. If institutions are to effectively integrate and retain IENs, acculturation needs must be clearly understood by nurse administrators, managers, educators, and nursing
www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
educated nurses
staff members. This article reports the qualitative findings and recommendations that emerged from a mixed methods study examining the acculturation experience of IENs who participated in an international residency program. Acculturation is “the adoption and assimilation of an alien culture” and includes “...phenomena which
www.nursingmanagement.com
result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups.”5 Acculturation refers to adjustment to U.S. nursing practice and to the cultural and social adjustment to life in the United States. The study hospital is an
American Nurses Credentialing Center Magnet®-designated, notfor-profit, urban teaching hospital with 864 licensed beds in Southeast Texas.
Biggest challenges IENs face many challenges with new ways of living, communication difficulties, and the U.S. scope of
Nursing Management • June 2014 31
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Internationally educated nurses
nursing practice, which varies significantly from that of other countries.6 For example, U.S. nurses assume greater responsibility and act as the care coordinator, routinely challenging physicians’ orders.7 In the Philippines, for instance, nursing care is technical and therapeutic, based more on the medical model than on the holistic nursing care model found in the United States.8 Differences emerge in elements of clinical practice, such as documentation of care, measurements, medication
communication—it’s easy to become overwhelmed with American accents, colloquialisms, and speed of speech. Communication barriers result in frustration for the IEN and his or her coworkers, physicians, and patients. Despite meeting the English language requirement by passing the Test of English as a Foreign Language (TOEFL), IENs aren’t guaranteed communicative competence.6 The TOEFL measures one’s ability to use and comprehend English at the university level.
A comprehensive nurse residency program that utilizes a systematic, organized approach may provide IENs with the necessary resources to lessen overwhelming challenges. names, and nurses’ interactions with patients.9,10 A comprehensive nurse residency program that utilizes a systematic, organized approach provides IENs with the necessary resources to lessen overwhelming challenges, speed acculturation, and help them cope effectively. More research is needed to plan and evaluate programs that meet learners’ needs and ensure that IENs remain committed to the organization.11 IEN programs are a direct result of the World Health Organization’s call for national action plans. The programs are an important strategy to improve patient care quality and safety, and promote the achievement of statutory outcomes and competencies required for nursing licensure.8 One of the most common and significant challenges IENs face is
However, emergencies in clinical settings don’t allow adequate time for mental translation, causing additional frustration and potential patient safety issues. Inappropriate word selection may result in “diminished credibility in the eyes of physicians and coworkers.”9 It’s been noted that IENs think healthcare providers ignore their comments because of a heavy foreign accent, rather than take the time to “wade through the accent” to understand the nurse’s message.12 The IENs’ nonverbal communication may differ from established norms, resulting in misinterpretation, which brands them as inattentive, subservient, or disrespectful. The IENs perspectives of their acculturation experience are important when evaluating the program. Standard program evaluation hasn’t historically produced rich feedback
32 June 2014 • Nursing Management
because IENs may feel constrained in discussing program deficiencies for fear of losing their jobs or being deported.13
Overcoming obstacles The study residency program was patterned after the institution’s graduate nurse residency program. Both programs were developed and coordinated by a clinical nurse specialist (CNS), and consist of three components: classroom orientation, clinical orientation, and a 1-year mentorship. Many IENs haven’t been exposed to computerized documenting, the use of modern equipment and technology, and various practice models in their nursing curriculum; therefore, additional topics were added to the program: telephone communication techniques, skills checkoff, physical assessment, and U.S. healthcare delivery system review. The program was designed to: 1) foster relationships among IENs and encourage them to build a community of support; 2) provide a safe learning environment that’s conducive for uninhibited questions; and 3) meet specific learning needs. Following 2 weeks of classroom instruction, IENs transitioned to assigned patient care units and were paired with a clinical preceptor for the duration of orientation. Depending on the IEN’s progress, clinical orientation lasted 4 to 5 months, during which time they were frequently visited by the CNS to evaluate progress and address individual needs. IENs participated in bimonthly, 8-hour staff development days in which they came together to share experiences, learning needs, and stories about adjustment to the institution and city. Education was provided on topics such as assertiveness, coping with change, www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
emotional I.Q., eating healthy in the United States, and financial planning. A “buddy system” provided additional support to classroom and clinical orientation and individual coaching. IENs were paired with nurses of the same cultural background who had lived in the United States for years, who served as a friend and guide during transition. Typical “buddy” assistance includes taking the IEN grocery shopping, to church, and to shopping malls, and inviting them to social activities such as birthday celebrations.
Background data The mixed methods design consisted of an observational survey with a qualitative descriptive study with ethnographic undertones. Standard data collection methodology for program evaluation consisted of handwritten evaluations from each participant. Participants who completed the handwritten evaluation also took part in group interview sessions. The same researcher-generated questions, formulated using culturally sensitive language, were used for both the handwritten survey and the semistructured interview guide. The questions were specifically designed to overcome barriers encountered with the use of written surveys in the (primarily) Filipino study sample. One example is: “You went back to your home country for a 4-week vacation. During this time, a fellow nurse asked you for some advice. S/he’s interested in coming to the United States. What advice would you give him or her so that he or she will be better equipped to practice nursing in the Unites States?” Following Institutional Review Board approval, purposive sampling was used through direct www.nursingmanagement.com
mail to invite IEN residency program participants to take part in the study. (See Table 1.) At the time of the group interview, IENs deposited sealed, handwritten surveys inside a box, which wasn’t opened until qualitative analysis was complete. Four group interviews were conducted and audio was recorded with two to four IENs per session. Recordings were transcribed word-for-word, and interview sessions were individually analyzed, coded, and interpreted by investigators to increase reliability of each reviewer’s separate interpretation of the data.14 An extensive audit trail was maintained. Following individual analysis and coding, both investigators reviewed and validated individual interpretations, returning to subsequent interviews for member checks.14 Through iterative thematic analysis, using Spradley’s ethnographic method, numerous cultural themes emerged.15,16
A world of difference Themes emerging from qualitative analysis were: 1) discordant expectations; 2) English language/ communication difficulties; 3) different nursing practice and education models; 4) cultural differences; 5) technology challenges; 6) feeling alone; and 7) need for support from others. Discordant expectations refer to the gap between IENs’ expectations of the United States and their actual experiences. IENs expected to find everything perfect here; they read and studied U.S.-authored books and assumed that nursing was practiced exactly as described. They quickly realized the practice variances. English language/communication difficulties emerged as the second theme. The TOEFL has limited ability to assess the sociocultural dimension of language, which plays a significant role in effective interpersonal communication. One IEN admitted, “I thought I knew how to speak English, but when I came
Table 1: Demographics of IEN participants Gender: Male Female Age Marital status: Married Single
Number
Percentage
1 10
9% 91%
Range 24 to 48 years
Average 36.7 years
8 3
73% 27%
Location of spouse: In United States Outside United States
7 1
91% 9%
Nuclear family in the United States: Yes No
7 4
64% 36%
Months in the United States:
internationally
Universal issues
By Claudia DiSabatino Smith, PhD, RN, NE-BC, and Judy Ong Ho, MSN, RN, ACNS-BC, CPHQ
I
nt nternationally n educated nurses (IENs) comprise 5.6% of the (IE RN RN workforce in the United 1 States. St Nursing experts suggest that this number will conge tinue to rise; the United States tin draws the highest number of d aws dr IENs.2,3 For decades, administrators have used international recruiting as one strategy for
30
overcoming the U.S. nursing shortage. IEN transition, integration, and retention are a significant concern, due to the number and expense of recruitment and orientation.4 Administrators have used international nurse residency programs to facilitate IEN integration into U.S. nursing practice culture and institutional culture; however,
June 2014 • Nursing Management
little research has focused on the IENs’ perspectives on the international residency program in acculturating and integrating them into U.S. nursing practice. If institutions are to effectively integrate and retain IENs, acculturation needs must be clearly understood by nurse administrators, managers, educators, and nursing
www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
educated nurses
staff members. This article reports the qualitative findings and recommendations that emerged from a mixed methods study examining the acculturation experience of IENs who participated in an international residency program. Acculturation is “the adoption and assimilation of an alien culture” and includes “...phenomena which
www.nursingmanagement.com
result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups.”5 Acculturation refers to adjustment to U.S. nursing practice and to the cultural and social adjustment to life in the United States. The study hospital is an
American Nurses Credentialing Center Magnet®-designated, notfor-profit, urban teaching hospital with 864 licensed beds in Southeast Texas.
Biggest challenges IENs face many challenges with new ways of living, communication difficulties, and the U.S. scope of
Nursing Management • June 2014 31
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Internationally educated nurses
nursing practice, which varies significantly from that of other countries.6 For example, U.S. nurses assume greater responsibility and act as the care coordinator, routinely challenging physicians’ orders.7 In the Philippines, for instance, nursing care is technical and therapeutic, based more on the medical model than on the holistic nursing care model found in the United States.8 Differences emerge in elements of clinical practice, such as documentation of care, measurements, medication
communication—it’s easy to become overwhelmed with American accents, colloquialisms, and speed of speech. Communication barriers result in frustration for the IEN and his or her coworkers, physicians, and patients. Despite meeting the English language requirement by passing the Test of English as a Foreign Language (TOEFL), IENs aren’t guaranteed communicative competence.6 The TOEFL measures one’s ability to use and comprehend English at the university level.
A comprehensive nurse residency program that utilizes a systematic, organized approach may provide IENs with the necessary resources to lessen overwhelming challenges. names, and nurses’ interactions with patients.9,10 A comprehensive nurse residency program that utilizes a systematic, organized approach provides IENs with the necessary resources to lessen overwhelming challenges, speed acculturation, and help them cope effectively. More research is needed to plan and evaluate programs that meet learners’ needs and ensure that IENs remain committed to the organization.11 IEN programs are a direct result of the World Health Organization’s call for national action plans. The programs are an important strategy to improve patient care quality and safety, and promote the achievement of statutory outcomes and competencies required for nursing licensure.8 One of the most common and significant challenges IENs face is
However, emergencies in clinical settings don’t allow adequate time for mental translation, causing additional frustration and potential patient safety issues. Inappropriate word selection may result in “diminished credibility in the eyes of physicians and coworkers.”9 It’s been noted that IENs think healthcare providers ignore their comments because of a heavy foreign accent, rather than take the time to “wade through the accent” to understand the nurse’s message.12 The IENs’ nonverbal communication may differ from established norms, resulting in misinterpretation, which brands them as inattentive, subservient, or disrespectful. The IENs perspectives of their acculturation experience are important when evaluating the program. Standard program evaluation hasn’t historically produced rich feedback
32 June 2014 • Nursing Management
because IENs may feel constrained in discussing program deficiencies for fear of losing their jobs or being deported.13
Overcoming obstacles The study residency program was patterned after the institution’s graduate nurse residency program. Both programs were developed and coordinated by a clinical nurse specialist (CNS), and consist of three components: classroom orientation, clinical orientation, and a 1-year mentorship. Many IENs haven’t been exposed to computerized documenting, the use of modern equipment and technology, and various practice models in their nursing curriculum; therefore, additional topics were added to the program: telephone communication techniques, skills checkoff, physical assessment, and U.S. healthcare delivery system review. The program was designed to: 1) foster relationships among IENs and encourage them to build a community of support; 2) provide a safe learning environment that’s conducive for uninhibited questions; and 3) meet specific learning needs. Following 2 weeks of classroom instruction, IENs transitioned to assigned patient care units and were paired with a clinical preceptor for the duration of orientation. Depending on the IEN’s progress, clinical orientation lasted 4 to 5 months, during which time they were frequently visited by the CNS to evaluate progress and address individual needs. IENs participated in bimonthly, 8-hour staff development days in which they came together to share experiences, learning needs, and stories about adjustment to the institution and city. Education was provided on topics such as assertiveness, coping with change, www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
emotional I.Q., eating healthy in the United States, and financial planning. A “buddy system” provided additional support to classroom and clinical orientation and individual coaching. IENs were paired with nurses of the same cultural background who had lived in the United States for years, who served as a friend and guide during transition. Typical “buddy” assistance includes taking the IEN grocery shopping, to church, and to shopping malls, and inviting them to social activities such as birthday celebrations.
Background data The mixed methods design consisted of an observational survey with a qualitative descriptive study with ethnographic undertones. Standard data collection methodology for program evaluation consisted of handwritten evaluations from each participant. Participants who completed the handwritten evaluation also took part in group interview sessions. The same researcher-generated questions, formulated using culturally sensitive language, were used for both the handwritten survey and the semistructured interview guide. The questions were specifically designed to overcome barriers encountered with the use of written surveys in the (primarily) Filipino study sample. One example is: “You went back to your home country for a 4-week vacation. During this time, a fellow nurse asked you for some advice. S/he’s interested in coming to the United States. What advice would you give him or her so that he or she will be better equipped to practice nursing in the Unites States?” Following Institutional Review Board approval, purposive sampling was used through direct www.nursingmanagement.com
mail to invite IEN residency program participants to take part in the study. (See Table 1.) At the time of the group interview, IENs deposited sealed, handwritten surveys inside a box, which wasn’t opened until qualitative analysis was complete. Four group interviews were conducted and audio was recorded with two to four IENs per session. Recordings were transcribed word-for-word, and interview sessions were individually analyzed, coded, and interpreted by investigators to increase reliability of each reviewer’s separate interpretation of the data.14 An extensive audit trail was maintained. Following individual analysis and coding, both investigators reviewed and validated individual interpretations, returning to subsequent interviews for member checks.14 Through iterative thematic analysis, using Spradley’s ethnographic method, numerous cultural themes emerged.15,16
A world of difference Themes emerging from qualitative analysis were: 1) discordant expectations; 2) English language/ communication difficulties; 3) different nursing practice and education models; 4) cultural differences; 5) technology challenges; 6) feeling alone; and 7) need for support from others. Discordant expectations refer to the gap between IENs’ expectations of the United States and their actual experiences. IENs expected to find everything perfect here; they read and studied U.S.-authored books and assumed that nursing was practiced exactly as described. They quickly realized the practice variances. English language/communication difficulties emerged as the second theme. The TOEFL has limited ability to assess the sociocultural dimension of language, which plays a significant role in effective interpersonal communication. One IEN admitted, “I thought I knew how to speak English, but when I came
Table 1: Demographics of IEN participants Gender: Male Female Age Marital status: Married Single
Number
Percentage
1 10
9% 91%
Range 24 to 48 years
Average 36.7 years
8 3
73% 27%
Location of spouse: In United States Outside United States
7 1
91% 9%
Nuclear family in the United States: Yes No
7 4
64% 36%
Months in the United States:
