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Use of foreign-educated nurses and patient satisfaction in U.S. hospitals Olena Mazurenko Nir Menachemi Purpose: In the context of value-based purchasing, this study examines the association between the utilization of foreign-educated registered nurses (RNs) and patient satisfaction among U.S. acute care hospitals. Data Sources/Study Setting: We utilized data from the Hospital Consumer Assessment of Healthcare Providers and Systems to measure patient satisfaction and data from the American Hospital Association regarding the utilization of foreign-educated RNs in 2012. Methodology/Approach: In this study, a cross-sectional design with propensity score adjustment to examine the relationship between use of foreign-educated nurses and 10 patient satisfaction outcome measures. Control variables include hospital size, ownership, geographic location, teaching status, system membership, a high-technology index, and U.S. region based on census categories. Findings: The utilization of foreign-educated RNs was negatively and significantly related to six patient satisfaction measures. Specifically, hospitals with foreign-educated RNs scored, on average, lower on measures related to nurse communication (" = j0.649, p = .01), doctor’s communication (" = j0.837, p e .001), communication about administered drugs (" = j0.539, p = .81), and communication about what to do during their recovery at home (" = j0.571, p = .01). Moreover, hospitals utilizing foreign-educated RNs scored, on average, lower on overall satisfaction measures including rating the hospital as 9 or 10 overall (" = j1.20, p = .005), and patients would definitely recommend the hospital (" = j1.32, p = .006). Practice Implications: Utilization of foreign-educated RNs is negatively associated with measures of patient satisfaction pertaining to communication and overall perceptions of care. Hospitals that utilize foreign-educated RNs should consider strategies that enhance communication competency and aid improving perception of care among patients.
T
he United States has experienced a nursing shortage in many areas of the country for approximately 6 decades (Brush, Sochalski, & Berger, 2004). The shortage is expected to continue with a projected 900,000 unfilled positions for registered nurses (RNs) by Key words: foreign-educated registered nurse, patient satisfaction, quality Olena Mazurenko, MD, PhD, is Assistant Professor, Health Care Administration and Policy, University of Nevada, Las Vegas. E-mail: [email protected]. Nir Menachemi, PhD, is Professor, Department Chair, Health Policy and Management, Indiana University. E-mail: [email protected]. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000077 Health Care Manage Rev, 2016, 00(0), 00Y00 Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
2030 (Juraschek, Zhang, Ranganathan, & Lin, 2012). Hospitals have employed various strategies to maintain an adequate RNYpatient ratio, including the use of foreigneducated nurses. Foreign-educated RNs most frequently migrate from Philippines, India, or Canada (Health Resources and Services Administration, 2010). The use of such nurses has increased over time, and approximately 15,000 foreign-educated nurses passed the U.S. RN licensure examination in 2005 (Aiken, 2007). Most of these RNs become U.S. citizens or permanent residents; thus, their presence in the workforce is likely to be long lasting (Neff, Cimiotti, Sloane, & Aiken, 2013). The widespread use of foreign-educated nurses has raised several concerns regarding the quality of care they deliver (Neff et al., 2013). First, a considerable number of foreigneducated RNs come to the United States from countries with transitional economies (e.g., Philippines, India) where substantially different health care systems exist with lower standards for licensure examinations (Aiken, 2007; Schumacher, 2011).
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Second, foreign-educated RNs may have language barriers and/or accents that may be difficult for hospital patients to understand, especially for those who are older. Finally, some empirical evidence indicates that the utilization of foreigneducated nurses in situations of poor nurse-to-patient ratios is associated with adverse patient outcomes, including surgical patient mortality and failure-to-rescue in the hospitals (Neff et al., 2013). The purpose of this study is to examine the association between the utilization of foreign-educated nurses and patient satisfaction among U.S. acute care hospitals. We utilize data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which is administered on behalf of the Center for Medicare and Medicaid Services. Given that hospital payments are now, in part, tied to HCAHPS scores, understanding the relationship between the use of foreign-educated nurses and patients’ perceptions of quality is increasingly important. Thus, the findings of the current study will be of interest to hospital human resource managers as well as nurse managers who are involved in RN recruitment decisions. In addition, our findings may be useful for policymakers interested in the development of immigration policies that impact foreign-educated nurses in the United States.
Conceptual Framework Two distinct theoretical frameworks can be used to explain how teams are affected by diverse memberships. The first, the information/decision-making perspective, poses that diversity in composition provides groups with a broader range of useful knowledge, skills and abilities, and the wider external network of resources on which diverse groups draw (Williams & O’Reilly, 1998). Health care teams with different professionals are associated with improved patient outcomes, including reduced mortality, better patient satisfaction, and lower cost (Gaboury, Bujold, Boon, & Moher, 2009; Mitchell, Parker, Giles, & White, 2010). The second theoretical mechanism through which diversity could influence team outcomes is the social identity and categorization theory (Tajfel & Turner, 1986). It suggests that perceived similarities and dissimilarities between members of a team provide a basis for categorization of individuals into groups based on their salient characteristics, such as gender, race, profession, and so forth. Individuals within a group are more likely to share information and have trusting relationships with each other than with the ‘‘outgroup’’ member. Social categorization theory is particularly relevant for the racially/ethnically diverse groups, especially when the team member interaction is high (Haas, 2010). Although evidence (Leonard, Levine, & Joshi, 2004) suggests that the context could be a moderating factor in the relationship between ethnic diversity and outcomes, no studies examined this hypothesis in the health care setting. On the basis of the social categorization theory, we hypothesize a negative relationship between utilization of foreign-
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educated RNs and patient satisfaction in U.S. hospitals that will primarily affect communication-related satisfaction measures. Evidence suggests that foreign-educated nurses tend to have communication deficiencies in both linguistic competence (pronunciation and speech) and sociocultural competence (Xu, 2007). Linguistic competence describes an individual’s ability to correctly pronounce words and engage in fluid speech that is understandable by others (PawlikowskaSmith, 2002). Sociocultural competence describes an individual’s knowledge of idioms and figurative language, knowledge of culture and customs, and uses of language though interaction skills to establish and maintain social relationships (Pawlikowska-Smith, 2002). Foreign-educated RNs may have sufficient mastery of the English language needed to be successful on licensure examinations but, compared with their U.S. trained counterparts, may have less of an understanding of local language culture including slang, regional accents, and the use of idioms and figurative language (Xu, 2007). Of all hospital personnel, inpatient nurses have the most frequent interactions with patients and family members, making their ability to effectively communicate a critical portion of patients’ perceptions of their hospital experience (Elliott, Kanouse, Edwards, & Hilborne, 2009). Furthermore, the patient could be viewing the foreign-educated RN as ‘‘outgroup’’ member because of pronounced differences in RNs racial/ ethnic background and accents/communication styles. It is not uncommon for patients to reject foreign-educated RNs because of deficient language skills that adversely affect their communication patterns (Baj, 1995). In addition, health care team members, such as other nurses and physicians, may also perceive a different racial/ethnic background as a reason to interact hastily and be unwilling to cooperate (Helmreich & Schaefer, 1994), which could adversely affect communication about patient care. Therefore, we hypothesize the following: Hypothesis 1: Patient satisfaction measures from the HCAHPS survey that assess nurse communication and/or overall satisfaction with the hospital experience would be negatively related to the utilization of foreigneducated RNs by hospitals. On the other hand, HCHAPS survey items that assess other important patient perceptions of the hospital stay (e.g., responsiveness of staff, cleanliness and quietness of the environment, and adequacy of pain management) are organizational and facility level characteristics that should not be related to the use of foreign-educated RNs. Thus: Hypothesis 2: Patient satisfaction measures from the HCAHPS survey that assesses cleanliness and quietness of the environment and adequacy of pain management would not be related to the utilization of foreigneducated RNs by hospitals.
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Foreign-Educated Nurses and Patient Satisfaction
Methods This study uses a cross-sectional design with propensity score adjustment to analyze the relationship between hospitals’ utilization of foreign-educated RNs and patient satisfaction. The data are drawn from two secondary sources: the American Hospital Association (AHA, 2012) Annual Survey of Hospitals and the Hospital Quality Alliance Hospital Compare (2012) data set. The main independent variable, utilization of foreign-educated RNs, as well as several hospital level characteristics, was extracted from the AHA database. The AHA survey is administered to all U.S. hospitals, but we focused specifically on general nonfederal acute care facilities only. Patient satisfaction items were obtained from the publicly available Hospital Quality Alliance Hospital Compare (2012) data set, which contains the information from the HCAHPS survey (Werner & Bradlow, 2006). The HCAHPS survey contains 10 patient perspectives on care: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, communicating about home recovery, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. It is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge. In July 2013, about 4000 hospitals publicly reported HCAHPS scores based on 3.1 million completed surveys. The data sets were merged by using the Medicare identification numbers.
Variables Our main independent variable is derived from the question, ‘‘Did your facility hire more foreign-educated nurses to help fill RN vacancies in 2012 versus 2011 (more, the same, less, did not hire)?’’ Consistent with previous research (Cho, Masselink, Jones, & Mark, 2011), we conflated this variable into a binary measure, where ‘‘more,’’ ‘‘the same,’’ and ‘‘less’’ categories were merged into one and coded as ‘‘hired’’ and the ‘‘did not hire’’ category was coded as zero. Control variables were derived from the AHA survey and included hospital size (measured as staffed beds), ownership (for profit, not-for-profit, governmental), geographic location (urban, rural), teaching status (whether the organization is a member of the Council of Teaching Hospitals and Health Systems), system membership (part of a system or independent), a high-technology index (a summated scale representing the presence of high-tech services including cardiac catheterization laboratory, open heart surgery, extracorporeal shock-wave lithotripter, megavoltage radiation therapy, nuclear magnetic resonance imaging, organ/tissue transplant, neonatal intensive care, certified trauma center; Zuckerman, Hadley, & Iezzoni, 1994), and U.S. region based on census categories (Northeast, Southeast, Midwest, West). The dependent variables in our models were the 10 HCHAPS patient satisfaction measures measured continuously. Specifically, each variable is presented as the per-
centage of patients, for a given hospital, who ranked their experience in the highest category for this item. For example, the patient had three options to choose from when was asked about nurse communication: Nurses always communicated well, usually communicated well, sometimes, or never communicated well. For the current analysis, the percentage of patients who selected the top category was used (e.g., ‘‘nurses always communicated well’’).
Statistical Analysis Data analysis was performed in SPSS Version 21.0 and included descriptive, bivariate, and regression analysis. Independent sample t tests were used to examine whether hospitals that hire foreign-educated RNs and their counterparts differed with respect to each of the patient satisfaction measures. Ordinary least square regressions were performed to assess the same relationship while also controlling for the hospital and geographical variables described above. We have adopted a stepwise approach to our model by entering only main independent variable and facility level characteristics in the first step. In the second step, we have added the variables that capture geographic information (rural/urban and region) and propensity scores. Given the cross-sectional nature of our data and the possibility that hospitals that hire foreign-educated RNs are different from their counterparts in unobservable ways, we utilized propensity scores to minimize the impact of selection bias on our findings. To do so, we calculated the predicted probability that a given hospital would hire foreigneducated RNs as a function of hospital size, ownership, census region, geographic location, teaching status, system membership, and high-technology index. The outputted predicted probabilities were then ranked and categorized into four strata that were included in our regression model as dummy variables. Results were flagged for significance at the levels of p G .05 and p G .01. The institutional review board of the primary author’s university approved this analysis
Results The analytic sample consisted of 3211 acute care general hospitals, with 424 (13.2%) of these utilizing foreign-educated RNs. Table 1 displays the organizational and geographical characteristics of hospitals that both utilized and did not utilize foreign-educated RNs. Hospitals that utilized foreign-educated RNs were more likely to be larger, urban, nonprofit, teaching facilities with more high-tech services in place. Hospital that employed foreign educated RNs were also more likely to be located in the south and west regions of the United States. Bivariate relationships between utilization of foreigneducated RNs and patient satisfaction measures are presented in Table 2. Hospitals that utilized foreign-educated RNs scored significantly lower in response to all HCAHPS questions (see Table 2), with the exception of item reflecting a patient recommendation of a hospital.
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Table 1
Organizational characteristics of hospitals by use of foreign-educated RNs
Bed size, M (SD) Ownership For profit Nonprofit Governmental Teaching status Yes No System membership Yes No Geographic location Urban Rural High-technology index, M (SD) Census divisions West Midwest Northeast South
Hospital uses foreign-educated RNs (N = 424)
Other (N = 2787)
p value
262.5 (251.3)
172.7 (200.7)
G.001
75 (17.7) 273 (64.4) 74 (17.5)
332 (11.9) 1866 (67) 585 (21)
.002
58 (25.2) 366 (12.3)
172 (74.8) 2615 (87.7)
G.001
277 (14.1) 147 (11.8)
1688 (85.9) 1099 (88.2)
.061
326 (17.6) 98 (7.2) 3.55 (2.2)
1527 (82.4) 1260 (92.8) 2.59 (2)
G.001 G.001
89 68 55 212
423 974 378 1002
G.001
(17.4) (6.5) (12.7) (17.5)
(82.6) (93.5) (87.3) (82.5)
RNs = registered nurses.
Table 3 reports the results of our regression analysis. The first column (Model A) presents regression results with only facility level characteristics, and the second column (Model B) presents regression results for the full model with geographic information and propensity scores. In Model A, the utilization of foreign-educated RNs was negatively related to many patient satisfaction measures. After controlling for geographic characteristics and propensity scores (Model B), all significant results in Model A retained their significance in Model B, indicating the stability of relationships. Specifically, hospitals with foreign-educated RNs scored, on average, lower on measures related to nurse communication (" = j0.649, p = .01), doctor’s communication (" = j0.837, p e .001), communication about administered drugs (" = j0.539, p = .81), and communication about what to do during their recovery at home (" = j0.571, p = .01). Moreover, hospitals utilizing foreign-educated RNs scored, on average, lower on overall satisfaction measures including rating the hospital as 9 or 10 overall (" = j1.20, p = .005), and patients would definitely recommend the hospital (" = j1.32, p = .006). In contrast, all other HCHAPS measures (e.g., those not pertaining to communication or overall satisfaction with the hospital experience) were not statistically related with the utilization of foreign-educated RNs (see Table 4). However, several control variables were consistently related to patient satisfaction. For example, as bed size increased, all patient satisfaction measures were more likely to be lower. Sim-
ilarly, an increase in the high-technology index is associated with lower patient satisfaction measures. On other hand, teaching status was associated with higher patient satisfaction measures.
Discussion The main finding of our study is that the use of foreigneducated RNs is negatively and significantly associated with lower scores on certain patient satisfaction measures including items related to how patients perceive the quality of communication from the health care team. Consistent with our Hypothesis 1, patients rated nursing communication, communication regarding medication use, and communication regarding plans after discharge lower in hospitals that employ foreign-educated nurses. Communication deficits are a documented challenge for foreign-educated RNs because of their unfamiliarity with U.S. culture and ‘‘informal’’ language such as slang and colloquialism (Davis & Nichols, 2002; Xu, Dayan, Lipkin, & Qian, 2008). Given the critical role that nurses play caring for patients, understanding and conveying symptoms to others on the health care team, and explaining treatment protocols, any deficits in communication may impact patients’ perceptions of their hospital experience (Elliott et al., 2009). Our results are congruent with previous research that examined the relationship between utilizing foreigneducated RNs and other quality measures such as 30-day
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Foreign-Educated Nurses and Patient Satisfaction
Table 2
Bivariate relationship between utilization of foreign-educated RNs and patient satisfaction among U.S. hospitals (N = 3211) % agreement among hospital respondents
Nurses always communicated well. Doctors always communicated well. Patients rate hospital as 9 or 10 overall. Patients would definitely recommend the hospital. Patients always received help as soon as they wanted. Pain was always controlled well. Patients who reported that staff always explained about medicines before giving it to them Patients who reported that, yes, they were given information about what to do during their recovery at home Patients who reported that the area around their room was always quiet at night Patients who reported that their room and bathroom were always clean
Hospitals utilizing foreign educated RNs, mean (SD)
Other, mean (SD)
t statistics
p value
76.3 79.5 68.3 70.4 63.8 69.7 61.4
78.1 81.4 70.0 71.0 66.5 70.6 63.0
(4.8) (5.0) (8.0) (9.0) (8.1) (5.0) (6.0)
6.61 6.91 3.46 1.29 6.07 3.39 4.76
G.001 G.001 G.001 .197 G.001 .001 G.001
83.0 (3.9)
84.1 (4.2)
4.79
G.001
58.5 (9.8)
59.6 (9.4)
2.03
.042
70.5 (6.6)
73.0 (7.2)
6.47
G.001
(5.0) (4.8) (7.8) (9.1) (8.5) (5.1) (5.5)
RNs = registered nurses.
mortality rates and failure to rescue (Neff et al., 2013). In addition, our analysis lends support to the social categorization theory in that our empirical findings are in general concordance with this theoretical framework. Importantly, our study also found that patients in hospitals that employ foreign-educated RNs also rate physician’s communication lower than their counterparts. This correlation may be because of the residual selection bias left over in our models after propensity score adjustment. In other words, it is possible that hospitals that employ foreign-educated RNs differ in unobservable ways from other hospitals and that those differences contribute to lower overall satisfaction. However, in line with our Hypothesis 2, our study did not find a relationship between employing foreign RNs and patient satisfaction on items related to room cleanliness, quietness at night, pain control, and attentiveness of staff. The room cleanliness and quietness at night are organizational/facility characteristics that may be influenced by factors other than foreign-educated RNs (e.g., structural characteristics of the building, janitorial services, etc.). The two other items, specifically pain control and attentiveness of staff, are measures that capture patient’s interactions with several clinical staff (e.g., nurse aids) and do not directly reflect the interaction between foreigneducated RNs and patients. Overall, we believe more research is needed to better understand the causal nature of why poorer satisfaction with communication issues is related to the use of foreign-educated RNs.
Our study also found statistically significant negative relationship between utilization of foreign-educated RNs and patient satisfaction measures that captured global perceptions such as willingness to recommend the hospital and overall hospital rating. Evidence suggests that nurses’ interaction and communication with patients is one of the most important factors affecting overall patient satisfaction in inpatient settings (Elliott et al., 2009; Glickman et al., 2010). Thus, the negative relationship, and the extent to which it is causal, between the use of foreign-educated RNs and patient satisfaction should be of interest to managers in hospitals that pursue this strategy. Several control variables were associated with lower patient satisfaction scores. We found that bed size was negatively associated with all patient satisfaction measures. This finding supports previous research that indicated that small hospitals (G100 beds) perform better with respect to patient satisfaction (Jha, Li, Orav, & Epstein, 2005; Lehrman et al., 2010), which could be explained by lower total volume of the patients that, perhaps, could allow medical staff to allocate more attention to each patient (Goldman & Dudley, 2008; Nawal Lutfiyya et al., 2007). In line with previous studies, we found that teaching status was associated with higher scores on patient satisfaction, which could be explained by positive public opinion about these institutions because of their focus on complex conditions and medical training/research activities (Ayanian & Weissman, 2002; Jha, Orav, Zheng, & Epstein, 2008). Finally, our results that revealed negative relationship
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Table 3
Multivariate relationship between utilization of foreign-educated RNs and patient satisfaction among U.S. hospitals (N = 3211) Patient satisfaction measure (percentage of patients who agree)
Utilization of foreign-educated RNs (yes) Bed size High-tech index System membership Ownership Government Nonprofit For profit Teaching hospital Urban location Census region West Midwest Northeast South Propensity strata Low Medium High Very high Adjusted R2
Nurses always communicated well
Doctors always communicated well
Staff always explained about medicines before giving them to patients
Model A, coef. (SE)
Model A, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
Model B, coef. (SE)
Model B, coef. (SE)
j1.05 (0.26)*** j0.64 (0.25)*** j0.84 (0.23)*** j0.93 (0.22)***j0.71 (0.31)** j0.53 (0.31)* j0.01 (0.01)*** j0.01 (0.01)*** j0.01 (0.01)*** j0.01 (0.01)*** j0.01 (0.01)***j0.05 (0.01)*** j0.32 (0.06)*** j0.15 (0.06)** j0.32 (0.06)*** j0.36 (0.05)*** j0.49 (0.07)***j0.36 (0.08)*** 0.15 (0.21) 0.11 (0.19) 0.02 (0.18) j0.21 (0.17) 0.11 (0.23) j0.05 (0.23) Reference
Reference Reference 0.92 (2.06) j1.45 (0.23)* j0.61 (2.06) j0.79 (0.31)* 1.28 (0.40)** 1.29 (0.39)** 0.79 (0.36)** Y j0.54 (0.26)** Y Y Y j2.59 (0.26)** j0.56 (0.29)** j2.10 (0.29)** Reference Y Y Reference j0.65 (0.32)** j1.61 (0.37)** j2.01 (0.49)** .12 .19 .21
Reference Reference Reference 5.59 (1.84)** j0.67 (0.30) j0.95 (0.49) 5.31 (1.85)** j1.18 (0.40) j1.67 (0.39) 1.31 (0.35)*** 2.45 (0.47)*** 2.83 (0.47)*** j2.02 (0.18)*** Y j1.43 (0.12)* Y j1.81 (0.24)*** j1.19 (0.31)*** j2.32 (0.26)*** j1.19 (0.35)*** j3.92 (0.26)*** j2.95 (0.36)*** Reference Reference Y Reference Reference j1.01 (0.29)*** j0.68 (0.39)* j2.24 (0.33)*** j1.63 (0.45)*** j2.16 (0.44)*** j1.55 (0.60)** .29 .11 .16
Note. High-tech index is a summated scale representing the presence of high-tech services including cardiac catheterization laboratory, open heart surgery, extracorporeal shock-wave lithotripter, megavoltage radiation therapy, nuclear magnetic resonance imaging, organ/tissue transplant, neonatal intensive care, and certified trauma center. coef = coefficient; RNs = registered nurses. *p G .1. **p G .05. ***p G .01.
between high-technology index and patient satisfaction also echo previous studies (Jha et al., 2005, 2008). There are several limitations to our analysis. First, the reliance on cross-sectional data makes it challenging to determine the causal nature of the relationships we examine. We utilized propensity score adjustment to minimize possible selection bias but recognize that this methodology cannot eliminate the influence of such confounding. Thus, the relationships we present can only be interpreted as associations. Future studies should seek longitudinal or experimental data to better identify the causal impact of utilizing foreign-educated RNs on patient satisfaction. Second, the utilization of foreign-educated RNs was obtained through the hospital’s reports of hiring these nurses during a
2-year period. This information, from the AHA survey, does not reflect the degree to which a hospital employs these RNs (full time vs. part time) or the proportion of foreigneducated RNs in a given hospital. Furthermore, our data did not allow us to determine the staffing ratios that are used by a given hospital. These items are known to affect patient outcomes; thus, future research should strive to incorporate them in the study design. In addition, it is plausible that hospitals that reported not utilizing foreign-educated RNs might have hired them in previous years. Therefore, contamination bias is possible if we categorized hospitals as not utilizing foreign-educated RNs if in fact they still employed some from previous periods. Finally, we cannot rule out the possibility of omitted variable bias. Despite our
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Foreign-Educated Nurses and Patient Satisfaction
Staff always gave patients information about what to do for recovery at home
Patients would rate hospital as 9 or 10 overall
Patient would definitely recommend the hospital
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
j0.95 (0.23)***
j0.57 (0.23)**
j1.25 (0.41)***
j1.21 (0.42)***
j1.38 (0.48)***
j1.32 (0.49)***
j0.01 (0.01)*** 0.22 (0.05)*** 0.34 (0.17)**
j0.04 (0.01)** 0.25 (0.06)*** 0.33 (0.17)**
j0.07 (0.01)*** 0.45 (0.10)*** 0.50 (0.33)
j0.07 (0.01)*** 0.32 (0.15)*** 0.09 (0.32)
j0.07 (0.01)*** 0.83 (0.12)*** 0.51 (0.37)
j0.06 (0.01)*** 0.78 (0.12)*** 0.26 (0.37)
Reference 0.81 (0.22)** 0.16 (0.30) 1.01 (0.35)*** Y Y
Reference j0.53 (1.86) j0.44 (0.18) 1.07 (0.35)** j0.68 (0.27)**
Reference 0.50 (0.48)* j0.49 (0.42)* 0.98 (0.65) Y Y
Reference 0.27 (3.45)* 0.77 (3.45)* 1.76 (0.62)** 2.21 (0.42)***
Reference 0.28 (0.47) j1.91 (0.64)* 1.36 (0.74)** Y Y
Reference 17.06 (3.89)*** 16.39 (3.90)*** 1.88 (0.73)* 4.51 (0.48)***
j0.79 (0.439)* j0.44 (0.49) j4.78 (0.49)*** Reference
0.81 (0.23)*** 1.35 (0.26)*** j0.01 (0.26) Reference Y
Y
.05
Reference j0.46 (0.29) j0.99 (0.34)** j1.60 (0.44)*** .07
.02
inclusion of commonly used hospital control variables, we recognize that any omitted variables may have impacted our results.
Practice Implications Patient satisfaction is receiving increased national attention because of the changes in Medicare reimbursements. Acute care hospitals are striving to increase patient satisfaction, despite ongoing nursing shortages, by employing foreigneducated RNs. Given the negative association we identify in our study and the potential for this relationship to be because of cultural and communication issues, hospital managers
0.33 (0.49) j0.99 (0.55)* j3.48 (0.56)*** Reference Y
Reference j2.93 (0.54)*** j4.31 (0.62)*** j3.16 (0.82)*** .07
.05
Reference j3.62 (0.61)*** j5.07 (0.71)*** j3.52 (0.96)*** .11
can take steps to minimize the ill effects on the patient experience. First, a managerial awareness of the negative relationship between the use of foreign-educated RNs and satisfaction is important. It is likely that language and cultural competence of foreign-trained RNs need to be done on a case-by-case basis. Variability is possible, if not likely, among RNs from the same foreign country in terms of pronunciation and speech. Moreover, there may be variability in foreign-educated RNs with respect to understanding local culture and customs specific to a hospital’s market. Thus, when appropriate, managers may need to design educational content that can be used when orienting new foreign-trained RNs to the hospital. To our knowledge, no evaluation of such a program exists in the
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Table 4
Multivariate relationship between utilization of foreign-educated RNs and patient satisfaction among U.S. hospitals (N = 3211) Patient satisfaction measure (percentage of patients who agree) Patients always received help as soon as they wanted
Room was always clean
Utilization of foreign-educated RNs (yes) Bed size High-tech index System membership Ownership Government Nonprofit For profit Teaching hospital Urban location Census region West Midwest Northeast South Propensity strata Low Medium High Very high Adjusted R2
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
j0.86 (0.14)
j0.45 (0.34)
j0.93 (0.39)
j0.31 (0.38)
j0.01 (0.01) j0.67 (0.08)*** j0.64 (0.27)**
j0.08 (0.01) j0.59 (0.09)*** j0.62 (0.26)**
j0.01 (0.01)*** j1.04 (0.09)*** j0.18 (0.30)
j0.09 (0.01)*** j0.82 (0.11)*** j0.28 (0.29)
Reference j0.15 (0.34) j2.43 (0.46)* 0.63 (0.54) Y Y
Reference j0.89 (2.82) j2.72 (2.82) 0.39 (0.53) j1.66 (0.35)***
Reference j0.98 (0.38) j2.41 (0.52)* 2.66 (0.60)*** Y Y
Reference 0.97 (3.11) j0.05 (3.12) 2.81 (0.58)*** j2.22 (0.39)***
j0.05 (0.36) 1.77 (0.40)*** 0.63 (0.41) Reference Y
.22
j1.03 (0.39)*** 0.35 (0.44) j3.03 (0.45)*** Reference Y
Reference j1.26 (0.44)** j1.76 (0.51)** j0.52 (0.67)** .26
.25
Reference j1.56 (0.48)*** j2.76 (0.56)*** j2.50 (0.74)*** .31
Note. High-tech index is a summated scale representing the presence of high-tech services including cardiac catheterization laboratory, open heart surgery, extracorporeal shock-wave lithotripter, megavoltage radiation therapy, nuclear magnetic resonance imaging, organ/tissue transplant, neonatal intensive care, and certified trauma center. coef = coefficient; RNs = registered nurses. *p G .1. **p G .05. ***p G .01.
literature. Thus, managers should also evaluate their efforts and report on lessons learned. Overall, just efforts have the potential to positively influence the patient experience and help determine whether the use of foreign RNs is causally linked to patient satisfaction. Given that foreign-educated RNs are a significant part of the nursing workforce and this trend will continue in the foreseeable future, more research is needed on this issue. References Aiken, L. H. (2007). US nurse labor market dynamics are key to global nurse sufficiency. Health Services Research, 42(3, Pt. 2), 1299Y1320. American Hospital Association. (2010). Retrieved January 4, 2015, from http://www.aha.org/research/rc/stat-studies/dataand-directories.shtml
Ayanian, J. Z., & Weissman, J. S. (2002). Teaching hospitals and quality of care: A review of the literature. The Milbank Quarterly, 80(3), 569Y593. Baj, P. A. (1995). Integrating the Russian e´migre´ nurse into U.S. nursing. The Journal of Nursing Administration, 25(3), 43Y47. Brush, B. L., Sochalski, J., & Berger, A. M. (2004). Imported care: Recruiting foreign nurses to U.S. health care facilities. Health Affairs, 23(3), 78Y87. Cho, S. H., Masselink, L. E., Jones, C. B., & Mark, B. A. (2011). Internationally educated nurse hiring: Geographic distribution, community, and hospital characteristics. Nursing Economics, 29(6), 308Y316. Davis, C. R., & Nichols, B. L. (2002). Foreign-educated nurses and the changing U.S. nursing workforce. Nursing Administration Quarterly, 26(2), 8. Elliott, M. N., Kanouse, D. E., Edwards, C. A., & Hilborne, L. H. (2009). Components of care vary in importance for overall patient-reported experience by type of hospitalization. Medical Care, 47(8), 842Y849.
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Foreign-Educated Nurses and Patient Satisfaction
Pain was always well controlled
Always quiet around room at night
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
j0.35 (0.26)
j2.75 (0.26)
j0.11 (0.47)
j0.28 (0.42)
j0.04 (0.01)*** j0.29 (0.06)*** 0.21 (0.20)
j0.04 (0.01)*** j0.23 (0.07)*** 0.11 (0.21)
j0.07 (0.01)*** j0.81 (0.11)*** 1.13 (0.36)**
j0.06 (0.01)*** j0.66 (0.11)*** 0.30 (0.32)
Reference j0.51 (0.26) j0.62 (0.35) 0.39 (0.41) Y Y
Reference 3.88 (2.17)* 3.42 (2.17) 0.68 (0.41)* j0.39 (0.23)
Reference j4.20 (0.46)** 1.61 (0.63)** 0.04 (0.73) Y Y
Reference j4.35 (3.40) j3.95 (3.41) 1.78 (0.64)*** 0.21 (0.42)
j1.57 (0.27)*** j1.07 (0.31)*** j2.19 (0.31)*** Reference Y
.07
Model B, coef. (SE)
j9.25 (0.43)*** j6.11 (0.48)*** j12.32 (0.49)*** Reference Y
Reference j0.33 (0.34) j0.91 (0.39)* j0.86 (0.52)* .11
Gaboury, I., Bujold, M., Boon, H., & Moher, D. (2009). Interprofessional collaboration within Canadian integrative healthcare clinics: Key components. Social Science & Medicine, 69(5), 707Y715. Glickman, S. W., Boulding, W., Manary, M., Staelin, R., Roe, M. T., Wolosin, R. J., I Schulman, K. A. (2010). Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circulation: Cardiovascular Quality and Outcomes, 3(2), 188Y195. Goldman, L. E., & Dudley, R. A. (2008). United States rural hospital quality in the Hospital Compare database-accounting for hospital characteristics. Health Policy, 87(1), 112Y127. Haas, H. (2010). How can we explain mixed effects of diversity on team performance? A review with emphasis on context. Equality, Diversity and Inclusion: An International Journal, 29(5), 458Y490. Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Retrieved from http://bhpr.hrsa.gov/ healthworkforce/rnsurvey/2008/nssrn2008.pdf
.16
Reference j2.22 (0.53)*** j4.12 (0.62)*** j3.55 (0.81)*** .38
Helmreich, R. L., & Schaefer, H. (1994). Team performance in the operating room. In Bognor M. S. (Ed.), Human error in medicine (pp. 225Y254). Hillsdale, NJ: Lawrence Erlbaum Associates. Hospital Quality Alliance Hospital Compare. (2012). Retrieved January 4, 2015, from http://www.hospitalcompare.hhs.gov Jha, A. K., Li, Z., Orav, E. J., & Epstein, A. M. (2005). Care in U.S. hospitalsVThe Hospital Quality Alliance program. The New England Journal of Medicine, 353(3), 265Y274. Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). Patients’ perception of hospital care in the United States. The New England Journal of Medicine, 359(18), 1921Y1931. Juraschek, S. P., Zhang, X., Ranganathan, V., & Lin, V. W. (2012). United States registered nurse workforce report card and shortage forecast. American Journal of Medical Quality, 27(3), 241Y249. Lehrman, W. G., Elliott, M. N., Goldstein, E., Beckett, M. K., Klein, D. J., & Giordano, L. A. (2010). Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care. Medical Care Research and Review, 67(1), 38Y55.
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Leonard, J. S., Levine, D. I., & Joshi, A. (2004). Do birds of a feather shop together? The effects on performance of employees’ similarity with one another and with customers. Journal of Organizational Behavior, 25(6), 731Y754. Mitchell, R., Parker, V., Giles, M., & White, N. (2010). Review: Toward realizing the potential of diversity in composition of interprofessional health care teams: An examination of the cognitive and psychosocial dynamics of interprofessional collaboration. Medical Care Research and Review, 67(1), 3Y26. Nawal Lutfiyya, M., Bhat, D. K., Gandhi, S. R., Nguyen, C., Weidenbacher-Hoper, V. L., & Lipsky, M. S. (2007). A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States. International Journal for Quality in Health Care, 19(3), 141Y149. Neff, D. F., Cimiotti, J., Sloane, D. M., & Aiken, L. H. (2013). Utilization of non-US educated nurses in US hospitals: Implications for hospital mortality. International Journal for Quality in Health Care, 25(4), 366Y372. Pawlikowska-Smith, G. (2002). Canadian Language Benchmarks 2000: Theoretical Framework. Schumacher, E. J. (2011). Foreign-born nurses in the US labor market. Health Economics, 20(3), 362Y378.
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Tajfel, H., & Turner, J. C. (1986). The social identity theory of intergroup conflict. In Worchel, S., & Austin, W. G. (Eds.), Psychology of intergroup relations (pp. 7Y24). Chicago, IL: Nelson-Hall. Werner, R. M., & Bradlow, E. T. (2006). Relationship between Medicare’s hospital compare performance measures and mortality rates. Journal of the American Medical Association, 296(22), 2694Y2702. Williams, K. Y., & O’Reilly, C. A. 3rd. (1998). Demography and diversity in organizations: A review of 40 years of research. In Staw, B. M., & Cummings L. L. (Eds.), Research in organizational behavior (pp. 77Y140). London, England: JAI Press. Xu, H., Dayan, P., Lipkin, R. M., & Qian, N. (2008). Adaptation across the cortical hierarchy: Low-level curve adaptation affects high-level facial-expression judgments. Journal of Neuroscience, 28(13), 3374Y3383. Xu, Y. (2007). Strangers in strange lands: A metasynthesis of lived experiences of immigrant Asian nurses working in Western countries. Advances in Nursing Science, 30(3), 246Y265. Zuckerman, S., Hadley, J., & Iezzoni, L. (1994). Measuring hospital efficiency with frontier cost functions. Journal of Health Economics, 13(3), 255Y280.
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Use of foreign-educated nurses and patient satisfaction in U.S. hospitals Olena Mazurenko Nir Menachemi Purpose: In the context of value-based purchasing, this study examines the association between the utilization of foreign-educated registered nurses (RNs) and patient satisfaction among U.S. acute care hospitals. Data Sources/Study Setting: We utilized data from the Hospital Consumer Assessment of Healthcare Providers and Systems to measure patient satisfaction and data from the American Hospital Association regarding the utilization of foreign-educated RNs in 2012. Methodology/Approach: In this study, a cross-sectional design with propensity score adjustment to examine the relationship between use of foreign-educated nurses and 10 patient satisfaction outcome measures. Control variables include hospital size, ownership, geographic location, teaching status, system membership, a high-technology index, and U.S. region based on census categories. Findings: The utilization of foreign-educated RNs was negatively and significantly related to six patient satisfaction measures. Specifically, hospitals with foreign-educated RNs scored, on average, lower on measures related to nurse communication (" = j0.649, p = .01), doctor’s communication (" = j0.837, p e .001), communication about administered drugs (" = j0.539, p = .81), and communication about what to do during their recovery at home (" = j0.571, p = .01). Moreover, hospitals utilizing foreign-educated RNs scored, on average, lower on overall satisfaction measures including rating the hospital as 9 or 10 overall (" = j1.20, p = .005), and patients would definitely recommend the hospital (" = j1.32, p = .006). Practice Implications: Utilization of foreign-educated RNs is negatively associated with measures of patient satisfaction pertaining to communication and overall perceptions of care. Hospitals that utilize foreign-educated RNs should consider strategies that enhance communication competency and aid improving perception of care among patients.
T
he United States has experienced a nursing shortage in many areas of the country for approximately 6 decades (Brush, Sochalski, & Berger, 2004). The shortage is expected to continue with a projected 900,000 unfilled positions for registered nurses (RNs) by Key words: foreign-educated registered nurse, patient satisfaction, quality Olena Mazurenko, MD, PhD, is Assistant Professor, Health Care Administration and Policy, University of Nevada, Las Vegas. E-mail: [email protected]. Nir Menachemi, PhD, is Professor, Department Chair, Health Policy and Management, Indiana University. E-mail: [email protected]. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000077 Health Care Manage Rev, 2016, 00(0), 00Y00 Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
2030 (Juraschek, Zhang, Ranganathan, & Lin, 2012). Hospitals have employed various strategies to maintain an adequate RNYpatient ratio, including the use of foreigneducated nurses. Foreign-educated RNs most frequently migrate from Philippines, India, or Canada (Health Resources and Services Administration, 2010). The use of such nurses has increased over time, and approximately 15,000 foreign-educated nurses passed the U.S. RN licensure examination in 2005 (Aiken, 2007). Most of these RNs become U.S. citizens or permanent residents; thus, their presence in the workforce is likely to be long lasting (Neff, Cimiotti, Sloane, & Aiken, 2013). The widespread use of foreign-educated nurses has raised several concerns regarding the quality of care they deliver (Neff et al., 2013). First, a considerable number of foreigneducated RNs come to the United States from countries with transitional economies (e.g., Philippines, India) where substantially different health care systems exist with lower standards for licensure examinations (Aiken, 2007; Schumacher, 2011).
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Second, foreign-educated RNs may have language barriers and/or accents that may be difficult for hospital patients to understand, especially for those who are older. Finally, some empirical evidence indicates that the utilization of foreigneducated nurses in situations of poor nurse-to-patient ratios is associated with adverse patient outcomes, including surgical patient mortality and failure-to-rescue in the hospitals (Neff et al., 2013). The purpose of this study is to examine the association between the utilization of foreign-educated nurses and patient satisfaction among U.S. acute care hospitals. We utilize data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which is administered on behalf of the Center for Medicare and Medicaid Services. Given that hospital payments are now, in part, tied to HCAHPS scores, understanding the relationship between the use of foreign-educated nurses and patients’ perceptions of quality is increasingly important. Thus, the findings of the current study will be of interest to hospital human resource managers as well as nurse managers who are involved in RN recruitment decisions. In addition, our findings may be useful for policymakers interested in the development of immigration policies that impact foreign-educated nurses in the United States.
Conceptual Framework Two distinct theoretical frameworks can be used to explain how teams are affected by diverse memberships. The first, the information/decision-making perspective, poses that diversity in composition provides groups with a broader range of useful knowledge, skills and abilities, and the wider external network of resources on which diverse groups draw (Williams & O’Reilly, 1998). Health care teams with different professionals are associated with improved patient outcomes, including reduced mortality, better patient satisfaction, and lower cost (Gaboury, Bujold, Boon, & Moher, 2009; Mitchell, Parker, Giles, & White, 2010). The second theoretical mechanism through which diversity could influence team outcomes is the social identity and categorization theory (Tajfel & Turner, 1986). It suggests that perceived similarities and dissimilarities between members of a team provide a basis for categorization of individuals into groups based on their salient characteristics, such as gender, race, profession, and so forth. Individuals within a group are more likely to share information and have trusting relationships with each other than with the ‘‘outgroup’’ member. Social categorization theory is particularly relevant for the racially/ethnically diverse groups, especially when the team member interaction is high (Haas, 2010). Although evidence (Leonard, Levine, & Joshi, 2004) suggests that the context could be a moderating factor in the relationship between ethnic diversity and outcomes, no studies examined this hypothesis in the health care setting. On the basis of the social categorization theory, we hypothesize a negative relationship between utilization of foreign-
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educated RNs and patient satisfaction in U.S. hospitals that will primarily affect communication-related satisfaction measures. Evidence suggests that foreign-educated nurses tend to have communication deficiencies in both linguistic competence (pronunciation and speech) and sociocultural competence (Xu, 2007). Linguistic competence describes an individual’s ability to correctly pronounce words and engage in fluid speech that is understandable by others (PawlikowskaSmith, 2002). Sociocultural competence describes an individual’s knowledge of idioms and figurative language, knowledge of culture and customs, and uses of language though interaction skills to establish and maintain social relationships (Pawlikowska-Smith, 2002). Foreign-educated RNs may have sufficient mastery of the English language needed to be successful on licensure examinations but, compared with their U.S. trained counterparts, may have less of an understanding of local language culture including slang, regional accents, and the use of idioms and figurative language (Xu, 2007). Of all hospital personnel, inpatient nurses have the most frequent interactions with patients and family members, making their ability to effectively communicate a critical portion of patients’ perceptions of their hospital experience (Elliott, Kanouse, Edwards, & Hilborne, 2009). Furthermore, the patient could be viewing the foreign-educated RN as ‘‘outgroup’’ member because of pronounced differences in RNs racial/ ethnic background and accents/communication styles. It is not uncommon for patients to reject foreign-educated RNs because of deficient language skills that adversely affect their communication patterns (Baj, 1995). In addition, health care team members, such as other nurses and physicians, may also perceive a different racial/ethnic background as a reason to interact hastily and be unwilling to cooperate (Helmreich & Schaefer, 1994), which could adversely affect communication about patient care. Therefore, we hypothesize the following: Hypothesis 1: Patient satisfaction measures from the HCAHPS survey that assess nurse communication and/or overall satisfaction with the hospital experience would be negatively related to the utilization of foreigneducated RNs by hospitals. On the other hand, HCHAPS survey items that assess other important patient perceptions of the hospital stay (e.g., responsiveness of staff, cleanliness and quietness of the environment, and adequacy of pain management) are organizational and facility level characteristics that should not be related to the use of foreign-educated RNs. Thus: Hypothesis 2: Patient satisfaction measures from the HCAHPS survey that assesses cleanliness and quietness of the environment and adequacy of pain management would not be related to the utilization of foreigneducated RNs by hospitals.
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Foreign-Educated Nurses and Patient Satisfaction
Methods This study uses a cross-sectional design with propensity score adjustment to analyze the relationship between hospitals’ utilization of foreign-educated RNs and patient satisfaction. The data are drawn from two secondary sources: the American Hospital Association (AHA, 2012) Annual Survey of Hospitals and the Hospital Quality Alliance Hospital Compare (2012) data set. The main independent variable, utilization of foreign-educated RNs, as well as several hospital level characteristics, was extracted from the AHA database. The AHA survey is administered to all U.S. hospitals, but we focused specifically on general nonfederal acute care facilities only. Patient satisfaction items were obtained from the publicly available Hospital Quality Alliance Hospital Compare (2012) data set, which contains the information from the HCAHPS survey (Werner & Bradlow, 2006). The HCAHPS survey contains 10 patient perspectives on care: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, communicating about home recovery, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. It is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge. In July 2013, about 4000 hospitals publicly reported HCAHPS scores based on 3.1 million completed surveys. The data sets were merged by using the Medicare identification numbers.
Variables Our main independent variable is derived from the question, ‘‘Did your facility hire more foreign-educated nurses to help fill RN vacancies in 2012 versus 2011 (more, the same, less, did not hire)?’’ Consistent with previous research (Cho, Masselink, Jones, & Mark, 2011), we conflated this variable into a binary measure, where ‘‘more,’’ ‘‘the same,’’ and ‘‘less’’ categories were merged into one and coded as ‘‘hired’’ and the ‘‘did not hire’’ category was coded as zero. Control variables were derived from the AHA survey and included hospital size (measured as staffed beds), ownership (for profit, not-for-profit, governmental), geographic location (urban, rural), teaching status (whether the organization is a member of the Council of Teaching Hospitals and Health Systems), system membership (part of a system or independent), a high-technology index (a summated scale representing the presence of high-tech services including cardiac catheterization laboratory, open heart surgery, extracorporeal shock-wave lithotripter, megavoltage radiation therapy, nuclear magnetic resonance imaging, organ/tissue transplant, neonatal intensive care, certified trauma center; Zuckerman, Hadley, & Iezzoni, 1994), and U.S. region based on census categories (Northeast, Southeast, Midwest, West). The dependent variables in our models were the 10 HCHAPS patient satisfaction measures measured continuously. Specifically, each variable is presented as the per-
centage of patients, for a given hospital, who ranked their experience in the highest category for this item. For example, the patient had three options to choose from when was asked about nurse communication: Nurses always communicated well, usually communicated well, sometimes, or never communicated well. For the current analysis, the percentage of patients who selected the top category was used (e.g., ‘‘nurses always communicated well’’).
Statistical Analysis Data analysis was performed in SPSS Version 21.0 and included descriptive, bivariate, and regression analysis. Independent sample t tests were used to examine whether hospitals that hire foreign-educated RNs and their counterparts differed with respect to each of the patient satisfaction measures. Ordinary least square regressions were performed to assess the same relationship while also controlling for the hospital and geographical variables described above. We have adopted a stepwise approach to our model by entering only main independent variable and facility level characteristics in the first step. In the second step, we have added the variables that capture geographic information (rural/urban and region) and propensity scores. Given the cross-sectional nature of our data and the possibility that hospitals that hire foreign-educated RNs are different from their counterparts in unobservable ways, we utilized propensity scores to minimize the impact of selection bias on our findings. To do so, we calculated the predicted probability that a given hospital would hire foreigneducated RNs as a function of hospital size, ownership, census region, geographic location, teaching status, system membership, and high-technology index. The outputted predicted probabilities were then ranked and categorized into four strata that were included in our regression model as dummy variables. Results were flagged for significance at the levels of p G .05 and p G .01. The institutional review board of the primary author’s university approved this analysis
Results The analytic sample consisted of 3211 acute care general hospitals, with 424 (13.2%) of these utilizing foreign-educated RNs. Table 1 displays the organizational and geographical characteristics of hospitals that both utilized and did not utilize foreign-educated RNs. Hospitals that utilized foreign-educated RNs were more likely to be larger, urban, nonprofit, teaching facilities with more high-tech services in place. Hospital that employed foreign educated RNs were also more likely to be located in the south and west regions of the United States. Bivariate relationships between utilization of foreigneducated RNs and patient satisfaction measures are presented in Table 2. Hospitals that utilized foreign-educated RNs scored significantly lower in response to all HCAHPS questions (see Table 2), with the exception of item reflecting a patient recommendation of a hospital.
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Table 1
Organizational characteristics of hospitals by use of foreign-educated RNs
Bed size, M (SD) Ownership For profit Nonprofit Governmental Teaching status Yes No System membership Yes No Geographic location Urban Rural High-technology index, M (SD) Census divisions West Midwest Northeast South
Hospital uses foreign-educated RNs (N = 424)
Other (N = 2787)
p value
262.5 (251.3)
172.7 (200.7)
G.001
75 (17.7) 273 (64.4) 74 (17.5)
332 (11.9) 1866 (67) 585 (21)
.002
58 (25.2) 366 (12.3)
172 (74.8) 2615 (87.7)
G.001
277 (14.1) 147 (11.8)
1688 (85.9) 1099 (88.2)
.061
326 (17.6) 98 (7.2) 3.55 (2.2)
1527 (82.4) 1260 (92.8) 2.59 (2)
G.001 G.001
89 68 55 212
423 974 378 1002
G.001
(17.4) (6.5) (12.7) (17.5)
(82.6) (93.5) (87.3) (82.5)
RNs = registered nurses.
Table 3 reports the results of our regression analysis. The first column (Model A) presents regression results with only facility level characteristics, and the second column (Model B) presents regression results for the full model with geographic information and propensity scores. In Model A, the utilization of foreign-educated RNs was negatively related to many patient satisfaction measures. After controlling for geographic characteristics and propensity scores (Model B), all significant results in Model A retained their significance in Model B, indicating the stability of relationships. Specifically, hospitals with foreign-educated RNs scored, on average, lower on measures related to nurse communication (" = j0.649, p = .01), doctor’s communication (" = j0.837, p e .001), communication about administered drugs (" = j0.539, p = .81), and communication about what to do during their recovery at home (" = j0.571, p = .01). Moreover, hospitals utilizing foreign-educated RNs scored, on average, lower on overall satisfaction measures including rating the hospital as 9 or 10 overall (" = j1.20, p = .005), and patients would definitely recommend the hospital (" = j1.32, p = .006). In contrast, all other HCHAPS measures (e.g., those not pertaining to communication or overall satisfaction with the hospital experience) were not statistically related with the utilization of foreign-educated RNs (see Table 4). However, several control variables were consistently related to patient satisfaction. For example, as bed size increased, all patient satisfaction measures were more likely to be lower. Sim-
ilarly, an increase in the high-technology index is associated with lower patient satisfaction measures. On other hand, teaching status was associated with higher patient satisfaction measures.
Discussion The main finding of our study is that the use of foreigneducated RNs is negatively and significantly associated with lower scores on certain patient satisfaction measures including items related to how patients perceive the quality of communication from the health care team. Consistent with our Hypothesis 1, patients rated nursing communication, communication regarding medication use, and communication regarding plans after discharge lower in hospitals that employ foreign-educated nurses. Communication deficits are a documented challenge for foreign-educated RNs because of their unfamiliarity with U.S. culture and ‘‘informal’’ language such as slang and colloquialism (Davis & Nichols, 2002; Xu, Dayan, Lipkin, & Qian, 2008). Given the critical role that nurses play caring for patients, understanding and conveying symptoms to others on the health care team, and explaining treatment protocols, any deficits in communication may impact patients’ perceptions of their hospital experience (Elliott et al., 2009). Our results are congruent with previous research that examined the relationship between utilizing foreigneducated RNs and other quality measures such as 30-day
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Foreign-Educated Nurses and Patient Satisfaction
Table 2
Bivariate relationship between utilization of foreign-educated RNs and patient satisfaction among U.S. hospitals (N = 3211) % agreement among hospital respondents
Nurses always communicated well. Doctors always communicated well. Patients rate hospital as 9 or 10 overall. Patients would definitely recommend the hospital. Patients always received help as soon as they wanted. Pain was always controlled well. Patients who reported that staff always explained about medicines before giving it to them Patients who reported that, yes, they were given information about what to do during their recovery at home Patients who reported that the area around their room was always quiet at night Patients who reported that their room and bathroom were always clean
Hospitals utilizing foreign educated RNs, mean (SD)
Other, mean (SD)
t statistics
p value
76.3 79.5 68.3 70.4 63.8 69.7 61.4
78.1 81.4 70.0 71.0 66.5 70.6 63.0
(4.8) (5.0) (8.0) (9.0) (8.1) (5.0) (6.0)
6.61 6.91 3.46 1.29 6.07 3.39 4.76
G.001 G.001 G.001 .197 G.001 .001 G.001
83.0 (3.9)
84.1 (4.2)
4.79
G.001
58.5 (9.8)
59.6 (9.4)
2.03
.042
70.5 (6.6)
73.0 (7.2)
6.47
G.001
(5.0) (4.8) (7.8) (9.1) (8.5) (5.1) (5.5)
RNs = registered nurses.
mortality rates and failure to rescue (Neff et al., 2013). In addition, our analysis lends support to the social categorization theory in that our empirical findings are in general concordance with this theoretical framework. Importantly, our study also found that patients in hospitals that employ foreign-educated RNs also rate physician’s communication lower than their counterparts. This correlation may be because of the residual selection bias left over in our models after propensity score adjustment. In other words, it is possible that hospitals that employ foreign-educated RNs differ in unobservable ways from other hospitals and that those differences contribute to lower overall satisfaction. However, in line with our Hypothesis 2, our study did not find a relationship between employing foreign RNs and patient satisfaction on items related to room cleanliness, quietness at night, pain control, and attentiveness of staff. The room cleanliness and quietness at night are organizational/facility characteristics that may be influenced by factors other than foreign-educated RNs (e.g., structural characteristics of the building, janitorial services, etc.). The two other items, specifically pain control and attentiveness of staff, are measures that capture patient’s interactions with several clinical staff (e.g., nurse aids) and do not directly reflect the interaction between foreigneducated RNs and patients. Overall, we believe more research is needed to better understand the causal nature of why poorer satisfaction with communication issues is related to the use of foreign-educated RNs.
Our study also found statistically significant negative relationship between utilization of foreign-educated RNs and patient satisfaction measures that captured global perceptions such as willingness to recommend the hospital and overall hospital rating. Evidence suggests that nurses’ interaction and communication with patients is one of the most important factors affecting overall patient satisfaction in inpatient settings (Elliott et al., 2009; Glickman et al., 2010). Thus, the negative relationship, and the extent to which it is causal, between the use of foreign-educated RNs and patient satisfaction should be of interest to managers in hospitals that pursue this strategy. Several control variables were associated with lower patient satisfaction scores. We found that bed size was negatively associated with all patient satisfaction measures. This finding supports previous research that indicated that small hospitals (G100 beds) perform better with respect to patient satisfaction (Jha, Li, Orav, & Epstein, 2005; Lehrman et al., 2010), which could be explained by lower total volume of the patients that, perhaps, could allow medical staff to allocate more attention to each patient (Goldman & Dudley, 2008; Nawal Lutfiyya et al., 2007). In line with previous studies, we found that teaching status was associated with higher scores on patient satisfaction, which could be explained by positive public opinion about these institutions because of their focus on complex conditions and medical training/research activities (Ayanian & Weissman, 2002; Jha, Orav, Zheng, & Epstein, 2008). Finally, our results that revealed negative relationship
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Table 3
Multivariate relationship between utilization of foreign-educated RNs and patient satisfaction among U.S. hospitals (N = 3211) Patient satisfaction measure (percentage of patients who agree)
Utilization of foreign-educated RNs (yes) Bed size High-tech index System membership Ownership Government Nonprofit For profit Teaching hospital Urban location Census region West Midwest Northeast South Propensity strata Low Medium High Very high Adjusted R2
Nurses always communicated well
Doctors always communicated well
Staff always explained about medicines before giving them to patients
Model A, coef. (SE)
Model A, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
Model B, coef. (SE)
Model B, coef. (SE)
j1.05 (0.26)*** j0.64 (0.25)*** j0.84 (0.23)*** j0.93 (0.22)***j0.71 (0.31)** j0.53 (0.31)* j0.01 (0.01)*** j0.01 (0.01)*** j0.01 (0.01)*** j0.01 (0.01)*** j0.01 (0.01)***j0.05 (0.01)*** j0.32 (0.06)*** j0.15 (0.06)** j0.32 (0.06)*** j0.36 (0.05)*** j0.49 (0.07)***j0.36 (0.08)*** 0.15 (0.21) 0.11 (0.19) 0.02 (0.18) j0.21 (0.17) 0.11 (0.23) j0.05 (0.23) Reference
Reference Reference 0.92 (2.06) j1.45 (0.23)* j0.61 (2.06) j0.79 (0.31)* 1.28 (0.40)** 1.29 (0.39)** 0.79 (0.36)** Y j0.54 (0.26)** Y Y Y j2.59 (0.26)** j0.56 (0.29)** j2.10 (0.29)** Reference Y Y Reference j0.65 (0.32)** j1.61 (0.37)** j2.01 (0.49)** .12 .19 .21
Reference Reference Reference 5.59 (1.84)** j0.67 (0.30) j0.95 (0.49) 5.31 (1.85)** j1.18 (0.40) j1.67 (0.39) 1.31 (0.35)*** 2.45 (0.47)*** 2.83 (0.47)*** j2.02 (0.18)*** Y j1.43 (0.12)* Y j1.81 (0.24)*** j1.19 (0.31)*** j2.32 (0.26)*** j1.19 (0.35)*** j3.92 (0.26)*** j2.95 (0.36)*** Reference Reference Y Reference Reference j1.01 (0.29)*** j0.68 (0.39)* j2.24 (0.33)*** j1.63 (0.45)*** j2.16 (0.44)*** j1.55 (0.60)** .29 .11 .16
Note. High-tech index is a summated scale representing the presence of high-tech services including cardiac catheterization laboratory, open heart surgery, extracorporeal shock-wave lithotripter, megavoltage radiation therapy, nuclear magnetic resonance imaging, organ/tissue transplant, neonatal intensive care, and certified trauma center. coef = coefficient; RNs = registered nurses. *p G .1. **p G .05. ***p G .01.
between high-technology index and patient satisfaction also echo previous studies (Jha et al., 2005, 2008). There are several limitations to our analysis. First, the reliance on cross-sectional data makes it challenging to determine the causal nature of the relationships we examine. We utilized propensity score adjustment to minimize possible selection bias but recognize that this methodology cannot eliminate the influence of such confounding. Thus, the relationships we present can only be interpreted as associations. Future studies should seek longitudinal or experimental data to better identify the causal impact of utilizing foreign-educated RNs on patient satisfaction. Second, the utilization of foreign-educated RNs was obtained through the hospital’s reports of hiring these nurses during a
2-year period. This information, from the AHA survey, does not reflect the degree to which a hospital employs these RNs (full time vs. part time) or the proportion of foreigneducated RNs in a given hospital. Furthermore, our data did not allow us to determine the staffing ratios that are used by a given hospital. These items are known to affect patient outcomes; thus, future research should strive to incorporate them in the study design. In addition, it is plausible that hospitals that reported not utilizing foreign-educated RNs might have hired them in previous years. Therefore, contamination bias is possible if we categorized hospitals as not utilizing foreign-educated RNs if in fact they still employed some from previous periods. Finally, we cannot rule out the possibility of omitted variable bias. Despite our
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7
Foreign-Educated Nurses and Patient Satisfaction
Staff always gave patients information about what to do for recovery at home
Patients would rate hospital as 9 or 10 overall
Patient would definitely recommend the hospital
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
j0.95 (0.23)***
j0.57 (0.23)**
j1.25 (0.41)***
j1.21 (0.42)***
j1.38 (0.48)***
j1.32 (0.49)***
j0.01 (0.01)*** 0.22 (0.05)*** 0.34 (0.17)**
j0.04 (0.01)** 0.25 (0.06)*** 0.33 (0.17)**
j0.07 (0.01)*** 0.45 (0.10)*** 0.50 (0.33)
j0.07 (0.01)*** 0.32 (0.15)*** 0.09 (0.32)
j0.07 (0.01)*** 0.83 (0.12)*** 0.51 (0.37)
j0.06 (0.01)*** 0.78 (0.12)*** 0.26 (0.37)
Reference 0.81 (0.22)** 0.16 (0.30) 1.01 (0.35)*** Y Y
Reference j0.53 (1.86) j0.44 (0.18) 1.07 (0.35)** j0.68 (0.27)**
Reference 0.50 (0.48)* j0.49 (0.42)* 0.98 (0.65) Y Y
Reference 0.27 (3.45)* 0.77 (3.45)* 1.76 (0.62)** 2.21 (0.42)***
Reference 0.28 (0.47) j1.91 (0.64)* 1.36 (0.74)** Y Y
Reference 17.06 (3.89)*** 16.39 (3.90)*** 1.88 (0.73)* 4.51 (0.48)***
j0.79 (0.439)* j0.44 (0.49) j4.78 (0.49)*** Reference
0.81 (0.23)*** 1.35 (0.26)*** j0.01 (0.26) Reference Y
Y
.05
Reference j0.46 (0.29) j0.99 (0.34)** j1.60 (0.44)*** .07
.02
inclusion of commonly used hospital control variables, we recognize that any omitted variables may have impacted our results.
Practice Implications Patient satisfaction is receiving increased national attention because of the changes in Medicare reimbursements. Acute care hospitals are striving to increase patient satisfaction, despite ongoing nursing shortages, by employing foreigneducated RNs. Given the negative association we identify in our study and the potential for this relationship to be because of cultural and communication issues, hospital managers
0.33 (0.49) j0.99 (0.55)* j3.48 (0.56)*** Reference Y
Reference j2.93 (0.54)*** j4.31 (0.62)*** j3.16 (0.82)*** .07
.05
Reference j3.62 (0.61)*** j5.07 (0.71)*** j3.52 (0.96)*** .11
can take steps to minimize the ill effects on the patient experience. First, a managerial awareness of the negative relationship between the use of foreign-educated RNs and satisfaction is important. It is likely that language and cultural competence of foreign-trained RNs need to be done on a case-by-case basis. Variability is possible, if not likely, among RNs from the same foreign country in terms of pronunciation and speech. Moreover, there may be variability in foreign-educated RNs with respect to understanding local culture and customs specific to a hospital’s market. Thus, when appropriate, managers may need to design educational content that can be used when orienting new foreign-trained RNs to the hospital. To our knowledge, no evaluation of such a program exists in the
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8
Health Care Management Review
Month & 2016
Table 4
Multivariate relationship between utilization of foreign-educated RNs and patient satisfaction among U.S. hospitals (N = 3211) Patient satisfaction measure (percentage of patients who agree) Patients always received help as soon as they wanted
Room was always clean
Utilization of foreign-educated RNs (yes) Bed size High-tech index System membership Ownership Government Nonprofit For profit Teaching hospital Urban location Census region West Midwest Northeast South Propensity strata Low Medium High Very high Adjusted R2
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
Model B, coef. (SE)
j0.86 (0.14)
j0.45 (0.34)
j0.93 (0.39)
j0.31 (0.38)
j0.01 (0.01) j0.67 (0.08)*** j0.64 (0.27)**
j0.08 (0.01) j0.59 (0.09)*** j0.62 (0.26)**
j0.01 (0.01)*** j1.04 (0.09)*** j0.18 (0.30)
j0.09 (0.01)*** j0.82 (0.11)*** j0.28 (0.29)
Reference j0.15 (0.34) j2.43 (0.46)* 0.63 (0.54) Y Y
Reference j0.89 (2.82) j2.72 (2.82) 0.39 (0.53) j1.66 (0.35)***
Reference j0.98 (0.38) j2.41 (0.52)* 2.66 (0.60)*** Y Y
Reference 0.97 (3.11) j0.05 (3.12) 2.81 (0.58)*** j2.22 (0.39)***
j0.05 (0.36) 1.77 (0.40)*** 0.63 (0.41) Reference Y
.22
j1.03 (0.39)*** 0.35 (0.44) j3.03 (0.45)*** Reference Y
Reference j1.26 (0.44)** j1.76 (0.51)** j0.52 (0.67)** .26
.25
Reference j1.56 (0.48)*** j2.76 (0.56)*** j2.50 (0.74)*** .31
Note. High-tech index is a summated scale representing the presence of high-tech services including cardiac catheterization laboratory, open heart surgery, extracorporeal shock-wave lithotripter, megavoltage radiation therapy, nuclear magnetic resonance imaging, organ/tissue transplant, neonatal intensive care, and certified trauma center. coef = coefficient; RNs = registered nurses. *p G .1. **p G .05. ***p G .01.
literature. Thus, managers should also evaluate their efforts and report on lessons learned. Overall, just efforts have the potential to positively influence the patient experience and help determine whether the use of foreign RNs is causally linked to patient satisfaction. Given that foreign-educated RNs are a significant part of the nursing workforce and this trend will continue in the foreseeable future, more research is needed on this issue. References Aiken, L. H. (2007). US nurse labor market dynamics are key to global nurse sufficiency. Health Services Research, 42(3, Pt. 2), 1299Y1320. American Hospital Association. (2010). Retrieved January 4, 2015, from http://www.aha.org/research/rc/stat-studies/dataand-directories.shtml
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Foreign-Educated Nurses and Patient Satisfaction
Pain was always well controlled
Always quiet around room at night
Model A, coef. (SE)
Model B, coef. (SE)
Model A, coef. (SE)
j0.35 (0.26)
j2.75 (0.26)
j0.11 (0.47)
j0.28 (0.42)
j0.04 (0.01)*** j0.29 (0.06)*** 0.21 (0.20)
j0.04 (0.01)*** j0.23 (0.07)*** 0.11 (0.21)
j0.07 (0.01)*** j0.81 (0.11)*** 1.13 (0.36)**
j0.06 (0.01)*** j0.66 (0.11)*** 0.30 (0.32)
Reference j0.51 (0.26) j0.62 (0.35) 0.39 (0.41) Y Y
Reference 3.88 (2.17)* 3.42 (2.17) 0.68 (0.41)* j0.39 (0.23)
Reference j4.20 (0.46)** 1.61 (0.63)** 0.04 (0.73) Y Y
Reference j4.35 (3.40) j3.95 (3.41) 1.78 (0.64)*** 0.21 (0.42)
j1.57 (0.27)*** j1.07 (0.31)*** j2.19 (0.31)*** Reference Y
.07
Model B, coef. (SE)
j9.25 (0.43)*** j6.11 (0.48)*** j12.32 (0.49)*** Reference Y
Reference j0.33 (0.34) j0.91 (0.39)* j0.86 (0.52)* .11
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.16
Reference j2.22 (0.53)*** j4.12 (0.62)*** j3.55 (0.81)*** .38
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Month & 2016
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