Venturing into new territory

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Ways to support foreign-born nurses and help them adapt to U.S. practice

They travel over the border from Canada and across the world from China. But no matter where they were born and educated, international nurses are looking at U.S. hospitals as a place to call home. And this could mean great news in light of the country's looming nursing shortage.

"Because there has been a growth in the numbers of international nurses practicing within the U.S., it's captured the attention of many professional organizations," says Bette Case Di Leonardi, PhD, RN-BC, an independent nursing consultant in Chicago. "There are few who have not taken a position on it, in part because of the growing numbers and also because of concerns about the nursing shortage."

Indeed, the numbers are significant: There are about 90,000 foreign-trained nurses in the U.S. work force, according to a study in Health Affairs. The study noted that foreign-trained nurses now make up 4% of RNs in the country, with the largest numbers coming from the Philippines and Canada in the recent years.

"If the U.S.' policies doubled the numbers of international nurses recruited-as some other countries have done-this would represent some 100,000 additional nurses that would come from other countries with limited numbers of nurses," noted the authors of the Health Affairs article.

"The healthcare system in other parts of the world is different than it is in the U.S., so helping them adjust clinically and culturally is a critical piece of the puzzle we're trying to fill," says Karen Siroky, RN, MSN, senior director of education for San Diego-based AMN Healthcare, Inc., the largest healthcare staffing company in the country.

Often, foreign-born nurses immigrate to the United States seeking increased pay, broadened career opportunities, and first-rate working conditions that are sometimes lacking in other countries. Staff educators must be prepared to train these new nurses and help them successfully adapt to a foreign environment.

"Our world is a shrinking environment," says Maureen Connors Potter, RN, MSN, vice president for international services at HCPro, Inc., in Marblehead, MA. "So we have to turn and face the issue of nurse immigration."

The benefits and hurdles that travel along

There are many advantages that come with bringing international nurses to the workplace, says Case Di Leonardi, and the hiring of more nurses can assist in curbing the nursing shortage. These nurses bring more to the table than just an increase in the department's staffing numbers.

"International nurses certainly do bring professionalism to the practice setting," says Case Di Leonardi. "They may be a bit more formal with colleagues and patients and might be a bit less personal, but they definitely present a professional demeanor. And this earns them the respect of their peers."

Additionally, these skilled nurses bring an important element of diversity into the workplace, which is increasingly important with the recent influx of immigrants, says Siroky.

"The U.S. is an incredibly diverse nation, and helping diversify our healthcare work force can phenomenally aid the diverse patient population that we're serving," says Siroky. "It just increases our knowledge and gives us a rich global perspective."

Although these nurses will likely be positive influences in the work environment, there are also some possible hurdles that must be considered.

"It's time-consuming for a hospital to bring in an international nurse, and time equals money," adds Siroky. "So complete commitment to success is really the key."

The main focus of hospitals, says Potter, should continue to be the addressing of quality and patient safety.

"Communication is a key risk management issue for nursing and quality of patient care," she says.

Additionally, keep in mind that differences in language may also become a factor, adds Potter. "If the nurses are from other countries which are not English-speaking, you can sometimes encounter language barriers. And even if the nurses do speak English, there can be differences in the semantics."

Issues of ethics sometimes arise as well when it comes to nurses' immigration, as they will sometimes be arriving from other countries that are facing nursing shortages.

"There are ethical issues involved that need to be resolved by the individual professional nurses and the hospitals that are working on recruiting them," says Potter.

The educator's role

The first step for educators after the hiring of a foreign-born nurse, says Case Di Leonardi, is assessment. And because educators must be particularly thorough in their assessment of these nurses, it is increasingly important to avoid merely asking whether they have performed a certain task or demonstrated a particular skill. Yes or no questions lend themselves to misunderstandings, she says.

"Their role is different now," she adds. "They might have cared for a patient who had a central line in place, but the monitoring was the physician's responsibility. It's not enough to ask in a checklist fashion, 'Have you cared for a patient who had a femoral sheath?' Instead you have to ask, 'What has been your experience with the patient in this aspect of care?' "

On the same note, realize that hospital units can vary greatly in composition from country to country, says Siroky. "With ICUs, for example, you see similarities across the U.S.," she says. "But an ICU in another country may not be the same thing."

It is also useful to ask the nurses about their typical day in their previous practice setting to find out about the differences in practice and in the scope of practice expectations.

Another important role for educators is to make sure new nurses obtain the basic skill sets for the field and the facility in order to gain the complete confidence of their peers.

"It's important that staff educators provide the opportunity for these nurses to become comfortable with the skills they are expected to perform and the equipment they are expected to use before they actually begin to practice," says Case Di Leonardi.

Although it's vital that the international nurses become competent in these technical skills, it's also very helpful for them to learn from the experiences of their fellow nurses, and vice versa. "Have staff members get to know the nurse and the nurse's previous experience," says Case Di Leonardi. "Nurses love to tell stories to each other. They might need encouragement to tell their stories, but learning by examples is important."

As staff members begin learning about the new nurse, make them aware of any cultural differences that might arise in the working environment. Many cultures, for example, contain healthcare workers that expect a little less self-assertiveness from a nurse than what is expected in the professional role in the United States, says Case Di Leonardi.

"In some cultures the male physicians and other authority figures are treated with great deference, leading to some loss of assertiveness on the part of the nurse," she says. "We don't want anyone to consider being disrespectful, but it's expected that the nurse speak up if things are unclear."

Additionally, educators needs to avoid training all international nurses as a whole entity, as gaps in learning can vary from culture to culture depending on where the nurse originated. "You can't lump all international nurses into one group," says Siroky. "It really does vary by the country they're coming from."

Techniques for the preceptor

In most facilities, when preceptors are trained for a new nurse, they are given information about the individual, including cultural differences. This is especially essential when it comes to a foreign-born nurse, says Case Di Leonardi.

"Precepting techniques, such as active listening, are even more important when you're precepting someone from a different culture," she says.

Thus, the preceptor should make a point of learning the nurse's cultural background and showing him or her how staff members in the facility interact.

"This might not be as important for a domestic nurse, as they've had those experiences as students, but that's something the foreign nurses really need to see in action," says Case Di Leonardi.

Additionally, she notes, international nurses should be trained on how they can work most effectively with -preceptors.

"Something I've learned over the years in education is we train people for certain roles, but there's always someone on the receiving end of that role who could use some orientation as well," she says. "And that comes into play with the relationship between a preceptor and international nurse."


Aiken, L., Buchan, J., Sochalski, J., Nichols, B., and Powell, M. (2004). "Trends in international nurse migration," Health Affairs 23(3): 69-77.